Lee County Medical Society - Annual Medical Service Awards Nomination Form

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Annual Medical Service Awards Nominating Form -- Deadline is MAY 15, 2019

E-mail Address: *

First Name *

Middle Initial *

Last Name *

Address *

City/State/Zip *

Business Telephone *

Board Certification(s) *

Is the nominee currently a resident of Lee County? *

Nominee's current or past physician practice located in Lee County? *

While not required, if you have access to the nominee's resume/CV, please attach to this nominating form.

Attach a Resume:

I nominate the above for the following physician award(s): *

Citizenship & Community Service Award
Health Education Award
Leadership & Professionalism Award
Lifetime Achievement Award

I nominate the above for the following non-physician award(s): [note: Must be resident of Lee County]

Non-Physician Appreciation Award
Distinguished Layperson’s Award

We must be able to contact you if we have questions regarding your nominee.

Submitted by:

Your email address (when available): *

Your Phone Number:

Sponsor Comments: (Please use additional sheet as needed)

Why are you nominating this person? Please also tell a little about yourself. *

Deadline for submission is May 15th. Any nominations received after the deadline will not be accepted and will have to be resubmitted for the following year.

* Required

The Lee County Medical Society Foundation is a 501C3. # 81-4328651

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