SMA: Southern Medical Association - Award Nomination Form

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Southern Medical Association Alliance>SMAA Awards, Exhibits and Judging

Award Nomination Form

Click here to download the printable version of this form

(To be used for Health Education Award of Excellence for an Auxiliary Member(s), Health Education Award of Excellence, Medical Heritage Award of Excellence, and Doctor’s Day Award of Excellence for an SMA Member Physician) PLEASE REFER TO SPECIFIC ELIGIBILITY REQUIREMENTS FOR EACH AWARD contained in the reference materials.

Required Attachments:
Nominee’s Curriculum Vitae (if appropriate)
Primary Letter of Nomination (limited to 4 typed, double-spaced pages)

Optional Attachments:
Up to three (3) Letters of Support for the Nomination (limited to 1 typed page)

Nominee:
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Nominator:
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Concisely highlight the following information – expound where necessary.
Define the specific contribution of the Nominee which qualify him/her/it for this recognition.
Elaborate on the impact the community and the welfare of the general public.
In the case of an individual, describe the personal qualities which encouraged you to nominate this Nominee.
In the case of an organization, the mission of the organization and how it has been implemented successfully.

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