Physician Citizen of the Year Award nomination form

Physician Citizen of the Year Award nomination form
Nominations close December 31, 2019.

Please use the form below to tell us about a physician you think is deserving of this honor.

Here are the requirements:
1. The physician must be a Wisconsin resident.
2. The physician must be a medical doctor (MD) or doctor of osteopathy (DO).
3. Except in unusual circumstances, the service to the community should be uncompensated.
4. Previous winners of the award are not eligible.
Nominee information:
Name *

First Name Last Name Suffix
Clinic/hospital name *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Why do you believe the nominee should receive the Physician Citizen of the Year award?
Please give some specific examples of the extraordinary efforts the doctor has done for the community (community projects, public offices, civic service and charitable organizations, etc.).
Nomination made by:
Name *

First Name Last Name Suffix

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Email *

Confirmation Email A copy of your nomination will be sent to this address
Should be Empty: