Awards Program Common Application & Nominations Form

Please select which award you are applying or nominating someone else for:(Required)

Contact Information for the Nominee (You may self-nominate or nominate someone else.)

Name(Required)

First Last

Degrees(Required)

Title(Required)

Institution(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email(Required)

Does you identify as underrepresented in medicine (URM)?(Required)

Yes

*The APA defines URM using the AAMC's 2004 definition: "Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population," which includes the following racial and ethnic groups: Black or African American, Hispanic/Latino, Native American or Alaskan Native, Native Hawaiian and other Pacific Islander.

Ethnicity

African American

Asian

Caucasian, Non-Hispanic

Hispanic

Other

Prefer not to answer

Unknown

Please upload the nominee's statement.

Max. file size: 128 MB.

If required per the award application information.

Please upload the nominee's CV.(Required)

Max. file size: 128 MB.

Please upload two nomination letters below (one to two pages each). The letters should highlight the nominee’s accomplishments and explain why the nominee is deserving of the award. The letters can be written by you, a supervisor and/or a colleague.

Please upload letter of nomination #1(Required)

Max. file size: 128 MB.

Please upload letter of nomination #2(Required)

Max. file size: 128 MB.

Please upload statement from nominee (only required for Miller-Sarkin, please refer to website for details)

Max. file size: 128 MB.

The Teaching Program, Teaching Junior Faculty, and the Teaching Mid-Career Faculty awards require additional application materials. Please refer to the award pages to view the additional requirements and upload the additional required application materials here

Max. file size: 128 MB.

Only fill out this section if you are nominating a colleague

Full Name of Nominator if Different from Nominee

First Last

Degrees

Title

Institution

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Does the nominee identify as underrepresented in medicine (URM)?(Required)

Ethnicity

African American

Asian

Caucasian, Non-Hispanic

Hispanic

Other

Prefer not to answer

Unknown

Awards Program Common Application & Nominations Form

Awards Program Common Nominations Form

Contact Information for the Nominee (You may self-nominate or nominate someone else.)

Please upload two nomination letters below (one to two pages each). The letters should highlight the nominee’s accomplishments and explain why the nominee is deserving of the award. The letters can be written by you, a supervisor and/or a colleague.

Only fill out this section if you are nominating a colleague

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