COPIC Humanitarian Award Nomination Form - North Dakota

The COPIC Humanitarian Award is presented each year to honor a physician for volunteer medical services and contributions to their community. We specifically look to recognize those individuals who unassumingly volunteer outside the spectrum of their day-to-day lives.

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* 1. Nominee Information

Name

Address

Address 2

City

State

ZIP

Email Address

Phone Number

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* 2. Specialty

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* 3. Years in practice in North Dakota

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* 4. Member of North Dakota Medical Association (NDMA)?

Yes

NOMINATION DESCRIPTION

To help ensure that all candidates can be given equal consideration, we strongly recommend that you answer the following questions as they relate to the nominee's contributions to North Dakota's health care community.

You may also upload a pre-written statement (question 5 below) to answer the questions below. Please limit your narrative to no more than 2 pages.

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* 5. Written Statement Option (skip to #9 if choosing to attach statement)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 6. List and describe nominee's specific volunteer activities (where, what, when, how often, etc.)

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* 7. How do the nominee's volunteer activities specifically impact his/her community?

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* 8. Why do you feel this individual deserves to be recognized?

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* 9. Nomination submitted by:

Name

Organization

Address

Address 2

City

State

ZIP

Email Address

Phone Number

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* 10. If your nominee is not selected, may we let them know of your nomination?

Yes