Honorary Life Membership – Member Recommendation
Section 1: Member making the recommendation
Please provide your details as the recommending member
Your full name
*
Your email address
*
example@example.com
Your telephone number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently a member of the Taranaki Medical Foundation?
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Yes
No
Unsure
Is the nominee a:
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Current or former Taranaki medical practitioner
Other healthcare professional
TMF member or former member
Community member or supporter
Other individual who has made a significant contribution to the Foundation
Only current members of the Taranaki Medical Foundation may submit a recommendation for Honorary Life Membership
Your current role or area of practice
Section 2: Person being recommended
Please provide details about the nominee.
Full name of the person you are recommending
*
Professional title, qualifications or current/former role
Please describe the nominee’s connection with the Taranaki Medical Foundation or healthcare in Taranaki.
*
Approximately how long has the nominee contributed to the Foundation or its objectives?
Less than 5 years
5–10 years
11–20 years
More than 20 years
Unsure
Nominee’s email address or contact details, if known
Reasons for the Recommendation
Which objectives of the Foundation has the nominee’s service supported?
Which objectives of the Foundation has the nominee’s service supported?
Advancing medical research and healthcare knowledge
Supporting the education of doctors in Taranaki
Enhancing medical services for the Taranaki community
Strengthening relationships between primary and secondary care clinicians
Supporting the governance, sustainability or development of the Foundation
Other
Other
Why do you believe this person should be considered for Honorary Life Membership?
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Please describe their outstanding service, including specific examples, the length of their contribution and the impact it has had on the Foundation or its objectives.
In what way has their service been exceptional or beyond what would normally be expected?
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Is there any additional information you would like the Executive Committee to consider?
Optional
Supporting information
Please provide any supporting information for this recommendation.
Please provide the name and contact details of another person who could support or verify this recommendation.
Upload any supporting information
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Is there any other information the Committee should consider?
Nominee awareness
Nominees do not need to be approached before a recommendation is submitted. The Committee will determine when and how consent should be sought if the recommendation progresses.
Is the nominee aware that you are submitting this recommendation?
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Yes
No
Unsure
I would prefer the Committee to approach them if the recommendation progresses
Declaration
Please complete the declaration below.
I confirm that the information provided is accurate to the best of my knowledge. I understand that this submission is a confidential recommendation for consideration by the TMF Executive Committee and does not guarantee that the nominee will be put forward or elected as an Honorary Life Member. I consent to being contacted if further information is required.
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I confirm that the information provided is accurate to the best of my knowledge. I understand that this submission is a confidential recommendation for consideration by the Taranaki Medical Foundation Committee and does not guarantee that the nominee will be put forward or elected as an Honorary Life Member. I consent to being contacted if further information is required.
Electronic signature
*
Date submitted
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Month
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Day
Year
Date
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