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Published byJeremy Banks Modified over 6 years ago
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Name of Nominee : ____________________ Category : _____________________________
Date of Birth Are you affiliated with any organization Yes No If yes: Name of Organization ______________ Designation : ______________________ Address Referees Details ( 2) Name 1 : Organization: Relation to the Nominee: Name 2:
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How many years have you been working in this field
Describe the nature of your work ( location, speciality, activities etc.) How many years have you been working in this field
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If affiliated with any organization
(if applicable) Organization :___________ Designation : ___________ Responsibilities : ___________________ Impact of the activity ( can include patient success stories) People helped in the last 5 yrs
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Main source of funding Collaboration with other organizations / Individuals Recognition/ Achievement
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Any other information you would like to share
A brief (500 words max) describing your contribution in respect to the specific category you have nominated yourself. Any other information you would like to share
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