OMA Application Form

Name *

Address
Will not be shared

Phone *
Will not be shared

Email *
Will not be shared

LinkedIn Profile

Occupation/Title

Location/Region or City of Practice

Have you worked in a rural, Northern, or remote setting within Ontario? If yes, please list the location(s)

Area of Practice/Specialty
for physician applicants

CPSO Number
for physician applicants
I understand that my CPSO profile will be linked to my online profile for transparency purposes

Gender
self-describe

Background Checks *

I understand that references will be conducted, provided an OMA elections reference check has not been completed within the last 18 months or I have not participated in the OMA board director evaluation within the last 12 months (all applicants)

I understand that a social media check will be conducted (all applicants)

I understand that a criminal record check will be conducted (non-physician applicants)

Campaigning

The OMA is committed to ensuring an open, fair and transparent election campaign process — a level playing field for all. In declaring my candidacy, I agree to abide by all OMA election policies and procedures including the Elections Communications Guidelines. Contravention of my declared agreement may result in a notice of inappropriate conduct being communicated to the membership and/or a request to withdraw my candidacy.

I understand and agree to abide by these principles

Ontario Medical Association Publication (for physician applicants)
Candidate statements of interest and photos may be published on the OMA website.

I consent to having my statement of interest and photo included in the publication (print and /or digital)

Code of Conduct (for physician applicants)
I acknowledge that as a condition of my tenure as a Physician Leader, I must observe and comply with the rules, procedures and policies established by the Association from time to time, including but not limited to: the Member Code of Conduct and Civility, OMA Privacy policies, and the Respect and Safety in the Workplace policy and any updates ir future iterations of these, I understand that my failure to comply may result in disciplinary action, including but not limited to suspension or termination from any leadership position that I am elected or appointed to.

I understand and agree to abide by these principles

Statement of Interest
Briefly describe (200 words or less) why you are interested in becoming or continuing as a member of the OMA Board of Directors and what unique insights will you bring to support OMA’s mission? (Note this information will be shared with the OMA Membership).

Equity, Diversity, and Inclusion
Briefly describe (200 words or less) your commitment to and experience with equity, diversity, and inclusion, and how this could align with OMA’s goals and strategic vision? (Note this information will be shared with the OMA Membership).

Conflict of Interest
Applicants will have no real or perceived conflict of interest.
Potential conflicts of interest, for self or a family member, include affiliation with another board, committee, organization, vendor, supplier or any other party that has a direct or indirect interest in any business transaction or agreement with the OMA or payment of physicians which could result in benefit. It also includes involvement in any pending legal proceedings involving the OMA.

If you have any potential conflicts of interest, please specify

ResumePlease submit your resume in Microsoft Word format. Please do not include a photo or contact information (e.g., home address, phone number or email address) on your resume.

Photo
The OMA will reach out to each confirmed candidate to obtain a high-resolution photo for use during the OMA election.