13770 Plantation Road, Suite 1, Fort Myers, Florida 33912 - Tel: 239-936-1645
Annual Medical Service Awards Nominating Form -- Deadline is MAY 15, 2019
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 Outstanding 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 additional sheet as needed)
Why are you nominating this person? Please also tell a little about yourself.
Deadline for submission is May 15th of each year. Any nominations received after the deadline will not be accepted and will have to be resubmitted for the following year.