HCMA Alliance - Friend of Medicine Nomination Form
Nominating Member's Name
First Name
Last Name
Nominating Member's Email
example@example.com
Nominee's Name
First Name
Last Name
Nominee's Email
example@example.com
Reason for Nomination
Nominee’s Statement
Member's Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: