The FAFP Art of Medicine award was created in recognition of belief proven by personal example, that the patient receives the full benefit of total care only when the science of medicine is practiced as an art.

All nominations must include the following information to be eligible for consideration:
  • A completed nomination form via this application
  • Current Curriculum Vitae (attached below)
  • A maximum of eight pages of supporting documentation (attached below).
  • Color 5x7 professional photo (with high quality resolution)
The application and supporting documents (as noted above) must be sent together in this application and received at FAFP no later than June 30, 2020.  Questions, please contact Jennifer Young at jyoung@fafp.org or (904) 726-0944.

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* 1. Name of individual completing application (include email address):

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* 2. Physician Nominee Name:

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* 3. Physician AAFP/FAFP Member ID:

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* 4. Physician Home Address (include address, city, state and zip code):

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* 5. Physician Home Phone Number:

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* 6. Physician Office Address (include address, city, state and zip code):

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* 7. Physician Office Phone Number:

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* 8. Physician Email address:

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* 9. Please upload a copy of the physician's CV for review (limited to 3 pages):

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 10. Physician's Personal Statement (if applicable):

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 11. Please upload copies of supporting documentation (letters of support up to 8 pages)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 12. Please upload physician professional photograph (color 5x7 photograph)

GIF, JPEG, JPG, PNG file types only.
Choose File

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