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Award Nomination Form

Award Nomination Form

Review this nomination form and return when you have all required content to submit the form.

In the meantime, please email Keir Johnson, Awards Coordinator, to indicate your plans to submit a nomination and the name of the nominee.

Note: items with an asterisk (*) are required.

Learn more about the award categories here.

Nomination Form

Award Name *

Please select the Award that you are submitting a nomination for.

Your Information

Nominator's Name *

Nominator's Email *

Nominator's Phone Number *

Nominee’s Information

Candidate's Name *

Candidates Email *

Candidate's Phone Number *

Description *

Provide a brief description about why this candidate should be selected for this award. This is the “elevator pitch” that summarizes the candidate’s achievements and qualities. (Please limit to a maximum of 500 characters).

Documentation

Upload the following documentation (*indicates required documentation):

Curriculum Vitae*
List of academic or professional honours/awards*
List of publications and presentations
List of supporting awards and achievements (professional and personal)
Supporting press coverage

Upload here *

Upload any letters of reference or testimony from at least 2 individuals, including at least 1 non-physician. One of the individuals can include the nominator.* Attach documentation here. To upload multiple files, please hold CTRL (Windows) or CMD (Apple).

References

Please include information for up to three references or contacts (Name, email, phone for each)

Name *	Email *	Phone *

The deadline to receive nominations is December 4, 2023.

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