2025 G. William N. Fitzgerald Award for Excellence in Rural Surgery Nomination Form

 

Nominee Information

* is required

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Full Name*

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Institution*

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Phone Number*

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Email*

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Nominator Information

If you are nominating a colleague, please complete the section below.

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Full Name

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Institution

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Phone Number

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Email

Supporting Documentation

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Nominee's full CV*
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Two letters of reference in support of the nomination*
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Detailed letter that addresses the required elements as set out in the Nomination Criteria document*
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Submit