Distinguished Service Award Nomination Form

Award Nomination Form

Given in recognition of services rendered to patients and the community which have enhanced the image of the physician through devotion to the highest ideals of the medical profession and in the promotion of the art and science of medicine through teaching, writing, and administration.
  • Which award are you submitting a nomination for?
  • The following documentation must be submitted to support the nomination:

    Please note that only pdf, doc and docx documents will be accepted. Multiple documents may be uploaded.

    • Curriculum Vitae*
    • List of academic or professional honours/awards*
    • Personal testimony from at least 2 individuals (min. of 1 non-physician testimony)*
  • Drop files here or
    Accepted file types: pdf, doc, docx.
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    Optional

    • List of publications and presentations
    • List of supporting awards and achievements (professional and personal)
    • Supporting press coverage
  • Drop files here or
    Accepted file types: pdf, doc, docx.
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    Please provide up to 3 contacts who could provide additional supporting information:

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