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Lifetime Achievement Award Nomination Form
Please complete the application, assuming no one knows your nominee, including
detailed
information to assist the selection committee.
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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Email
*
Your email
Nominees Name:
*
Your answer
Nominated by (must be a member of SJMS)
*
Your answer
Dedication to high standards of medical practice:
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 medical and civic communities:
Your answer
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