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Young Physician Award Nomination Form
Please complete the application, assuming no one knows your nominee, and include
detailed
information to assist the selection committee. This award is intended for physicians under the age of 48.
You may submit additional information via email to
Lisa@sjcms.org
by February 14, 2025.
Dinner is scheduled for
Sunday, June 8
. If possible (without ruining the surprise), find out if your nominee will be available.
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Nominees Name:
*
Your answer
Nominated by (must be a SJMS Member):
*
Your answer
Dedication to high standards of the patients of their community:
Your answer
Dedication to the care and well-being of the patients of their community:
Your answer
Dedication to the support of physician colleagues in the medical community:
Your answer
Involvement in humanitarian activities:
Your answer
Involvement in community civic activities:
Your answer
Leadership in the medical and civic communities:
Your answer
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