North American Society Award - 2018 Nomination Form

Candidate Information

Which of the following aspects of professional endeavour does this candidate possess? (Candidates must mean at least two aspects.)

Current Position
Previous Position 1
Previous Position 2
First Nominator
Second Nominator
Third Nominator

Please provide a brief biographical sketch which describes the background and accomplishments of the nominee and how they meet the selection criteria of this award. Maximum of 500 words.

Letters of Reference

Please attach letters of reference for the candidate. If you would prefer to send the letters by mail or fax indicate so. All letters must be signed by the referee.

Supporting Documentation

Please attach any supporting documentation for this nomination (maximum 5 pages).

All letters and supporting documentation not attached to this submission must be received by the PHE Canada office by the nomination deadline.

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