Distinguished Service Award Nomination
I wish to nominate the following ANZAOMS member for a Distinguished Service Award to be presented at the ANZAOMS AGM.
1. Nominee (the person being nominated for an award)
Nominee's Name
*
First Name
Last Name
2. Referees
Name and contact details of referees who may be available to verbally support the nomination.
Referee 1
Referee 1 - Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Phone Number
Referee 2
Referee 2 - Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
3. Nomination
In my opinion, the nominee is deserving of this nomination for the following reason/s: Please provide details to support the Member's nomination as relates to the following criteria;
Service to the specialty:
*
Service to the local community:
*
Service to teaching and research:
*
Service to overseas aid and outreach:
*
Other elements relevant to the nomination:
*
Please attach a full CV of the nominee
*
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4. Your Information
Nominator Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Your E-mail Address
*
Signature
*
Date
*
-
Day
-
Month
Year
Date
Notes
Please keep all nominations confidential. If you have any queries regarding the nomination process please contact the ANZAOMS Executive Officer at eo@anzaoms.org. Your nomination will be shared with the ANZAOMS Awards committee for consideration. You may be contacted for further information as required. Nominations Close 30 April in the year of nomination.
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