The STFM Recognition Award

Nomination Form

I would like to nominate the following individual for the 2008 STFM Recognition Award.

Nominee ______________________________________________________

Institution ______________________________________________________

Address _______________________________________________________

City __________________________________________________________

State ___________________________________________ Zip ___________

Phone ______________________________ Fax ______________________

E-mail _________________________________________________________

This award recognizes an individual, who may or may not be an STFM member, for outstanding leadership in advancing family medicine as a discipline. The nominee’s achievements and activities should be clearly recognized as enhancing or supporting family medicine education by improving resources available for its support, by defense or support of its objectives, by serving as an outstanding role model, or by other notable service to the discipline. The activities should have significance at a national level.

Nominators are asked to collect the items listed in the criteria section and forward them as a packet to the STFM office by October 1, 2007 . Applications not meeting the requirements listed above will be returned to the nominator for resubmission.

Send 11 sets of the nomination materials to Traci Nolte, STFM, 11400 Tomahawk Creek Parkway, Ste 540, Leawood, KS 66211. 800-274-2237, ext. 5420, e-mail: tnolte@stfm.org.

Nominator _____________________________________________________

Institution ______________________________________________________

Address _______________________________________________________

City __________________________________________________________

State ___________________________________________ Zip ___________

Phone ______________________________ Fax ______________________

E-mail ________________________________________________________