Salute to Service Nomination Form - Medical Society of Virginia

Salute to Service Award Nomination Form

The Salute to Service Awards are generously presented by The Doctors Company. Nominations are accepted April through June annually.

"*" indicates required fields

Nominator Name*

Nominator Position*

Nominator Email*

Nominator Phone*

Nominee Name*

Nominee Position*

Nominee Email*

Nominee Phone*

Nominating Category*

Description of nominee's service that has impacted the health of the population served*

What, precisely, makes this nominee special?*

Please provide any additional comments or information you feel would be beneficial to the selection panel.*

Attach the Nominee's CV*

Max. file size: 50 MB.

Attach a Letter of Recommendation*

Max. file size: 50 MB.

Letter of recommendation must come from someone other than the nominator or the nominee.