Nomination Form 2008 AMA Young Physicians Section Community Service Award
Nominations must be received by May 1, 2008
Instructions Please complete this form. Note that some supporting materials must also be mailed to the AMA Department of Young Physician Services, 515 N. State Street, Chicago, IL 60654, or sent via fax, (312) 464-5845 Attn:YPS
The information you provide below is solely for the AMA's internal use and will not be resused or sold for any commercial purpose without your permission.
Project Title
Project Description Describe the community service activity in 150 words or less. Include information on the concern or issue the activity addressed, the project’s goal(s), target audience, and project duration. Attach (or mail) copies of any materials produced, and articles or news releases describing the project. If the program was evaluated in any way, include a copy of the evaluation data.
Rationale In 75 words or less, please indicate why you believe the project described above merits an AMA-YPS Community Service Award.
Information on Nominee. Name of Program, Organization, or Indivdual nominated:
Mailing Address:
Phone:
E-mail: Your e-mail address will not be shared, sold, traded, exchanged or rented. See our Privacy Policy for more information.
Information on Person submitting nomination: Complete only if different from above.
Name:
Letters of Support. If you received any letters of support or have other information you would like to have the AMA-YPS Governing Council review, summarize below and send a “hard copy” to the AMA Department of Young Physician Services, 515 N. State Street, Chicago, IL 60654; or fax to (312) 464-5845, Attn: AMA-YPS.
You may contact the Young Physicians Section via e-mail at yps@ama-assn.org.
