Awards Nomination Form

All fields are required.

Your Name:

Your Organization:

Your City:

Your Phone:

Your Email

Please select the appropriate award(s) and complete the information for nominee.

Use Ctrl+click to select multiple awards
—Please choose an option—President's AwardMerit AwardSharon Martin Award for Community DevelopmentPhyllis M. Baird Memorial Award for Public Health NursingHealthy Corporate Citizen AwardSignificant Contributions to Public Health Practice

Nominee Information

Nominee's Name:

Nominee's Email

Nominee's Organization:

Nominee's Street Address:

Nominee's City:

Nominee's Province:

Nominee's Postal Code:

Nominee's Phone:

Why do you think this person is a good candidate for the award?

Upload your letter of support:

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