13770 Plantation Road, Suite 1, Fort Myers, Florida 33912 - Tel: 239-936-1645
Annual AMSA AWARDS Nominating Form
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
Scientific Achievement Award
Health Education Award
Leadership & Professionalism Award
Rising Physician Award
Lifetime Achievement Award
In Memory of an Oustanding Physician 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.
Your email address (when available):
Your Phone Number:
Sponsor Comments: (Please use additonal sheet as needed)
Why are you nominating this person? Please also tell a little about yourself.
Deadline for sumbission is May 15th of each year. Any nominations received after the dealine will not be acccepted and will have to be resubmitted for the following year.