Menu
Physician Awards Nomination Form

Physician Awards Nomination Form

Nomination Period: December 17, 2024 - January 17, 2025

Nominate a family physician today by completing all of the fields on this form. Please review the list of eligibility requirements for candidates below:

 

  • Must be a family physician and member of the AAFP/PAFP who has renewed their membership for 2025.
  • Nominee is an exemplary role model who has contributed significantly to the practice of family medicine (Family Physician of the Year), or the public health of their community (Public Health Award), or to the education of residents and students (Exemplary Teaching Award).
  • Selected winners must be able to attend the Spring 2025 PAFP Connect Conference on April 5.
FOR WHICH AWARD ARE YOU NOMINATING? (Please Choose One):
NOMINEE INFORMATION:
First:  
Last:  
Credentials:
Cell No.:
Email:
Practice/Medical School/Residency Program Name:
YOUR INFORMATION:
First:  
Last:  
Credentials:
Cell No.:
Email:
Your Practice/Medical School/Residency Program Name:
Curriculum Vitae (OPTIONAL Upload - PDF or Word Document):
  • Uploaded % ( ) Total
  • Uploaded files: % () Total files:
  • Uploading file:
  • Elapsed time:  Estimated time:  Speed:
WARNING: Due to security issues in place on Apple iOS devices, uploading files could be problematic. General use PC and other computer devices will work just fine. Please contact Brent Ennis at bennis@pafp.com to make other arrangements as necessary.
NOMINATION DESCRIPTION:
If nominating yourself or another, please explain why this person deserves either the Family Physician of the Year, Public Health Award, or Exemplary Teaching Award.
(500 words maximum - 0 words)

FORM VERIFICATION:


Enter text from image above: