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PA Family Physician of the Year Nomination Form
* Denotes Required Fields
View Eligibility Requirements for Candidates
Nominee Information
We need information regarding the family physician that is being nominated for the PA Family Physician of the Year award for calendar year 2018.
Physician Name: * 
Practice Name: * 
Practice Address: *
City State Zip
Practice Phone No.: * 
Your Information
We need information about you to process and confirm your submission. We will never share this information with outside parties, and we will contact you only about this nomination.
Name: * 
City State Zip
Phone No.:
Email Address: * 
How Did You Hear About This Award:
Tell us why this physician should be PA Family Physician of the Year. Provide as much information as possible below: *  
Eligibility Requirements for Candidates

A family physician who:

- Provides his/her patients with compassionate, comprehensive and caring family medicine on a continuing basis;

- Is directly and effectively involved in community affairs and activities that enhance the quality of his/her community;

- Provides a credible role model professionally and personally to his/her community, to other health professionals, and residents and medical students;

- Can effectively represent the specialty of family practice and the AAFP in public speaking;

- Is in good standing in his/her medical community;

- Is a member of the American Academy of Family Physicians/PA Academy of Family Physicians.

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