AMA-WPS Inspirational Physician Award Nomination Form

The American Medical Association (AMA) Women Physicians Section (WPS) acknowledges physicians who contribute in often unsung ways to our individual success. These individuals may have steered you into the specialty you love, helped you find work/life balance, guided you through your professional society or served as an important role model.

Each year, through the AMA-WPS Inspirational Physician Award, we recognize those individuals who have made a difference in our professional lives. Recipients will be:

  • Issued a special certificate and recognized at the AMA House of Delegates meeting
  • Celebrated during September Women in Medicine Month
  • Acknowledged through AMA communications vehicles such as AMA Morning Rounds and the AMA-WPS website

Please take a moment today to show your appreciation. Nominees must be members of the AMA.

Contact Information

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Denotes a required field
Your First Name
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Your Last Name
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Address
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Address Line 2
 
City
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State
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ZIP Code
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Phone
 
000-000-0000
AMA Member?
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Yes
No

The following person should be recognized as one who has provided important mentorship, support or inspiration. The individual will be contacted by the AMA-WPS for approval before being named in any public recognition.

Physician Nominee First Name
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Physician Nominee Last Name
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Address
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Address Line 2
 
City
*
State
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ZIP Code
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Phone
 
000-000-0000
Email
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Please provide a brief description on why this physician should be recognized and how she or he has made a difference in your life. (Please limit your response to 100 words):*