Question Title

* 1. Please select which award you are applying or nominating someone else for:

Contact Information for the Nominee
(You may self-nominate or nominate someone else.)

Question Title

* 2. Full Name of Nominee (with designations)

Question Title

* 3. Institution

Question Title

* 4. Title

Question Title

* 5. Does this person (or you, if self-nominating) identify as a URM?
*The APA defines URM using the AAMC's 2004 definition: "Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population," which includes the following racial and ethnic groups: Black or African American, Hispanic/Latino, Native American or Alaskan Native, Native Hawaiian and other Pacific Islander.

Question Title

* 6. Address 1

Question Title

* 7. Address 2

Question Title

* 8. City, State  Zip

Question Title

* 9. Email:

Question Title

* 10. Phone Number:

Question Title

* 11. Please upload the nominee’s CV.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File
Please upload two nomination letters below (one to two pages each). The letters should highlight the nominee’s accomplishments and explain why the nominee is deserving of the award. The letters can be written by you, a supervisor and/or a colleague.

Question Title

* 12. Please upload letter of nomination #1.

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

Question Title

* 13. Please upload letter of nomination #2.

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

Question Title

* 14. Please upload letter of nomination #3 (only required for Miller-Sarkin).

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

Question Title

* 15. Please upload letter of nomination #4 (only required for Miller-Sarkin).

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

Question Title

* 16. Please upload statement from nominee (only required for Miller-Sarkin, please refer to website for details)

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

Question Title

* 17. The Teaching Program, Teaching Junior Faculty, and the Teaching Mid-Career Faculty awards require additional application materials. Please click on the links above to view the additional requirements. Please upload the additional required application materials here.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File
Only fill out this section if you are nominating a colleague.

Question Title

* 18. Full Name of Nominator if Different from Nominee (with designations):

Question Title

* 19. Institution:

Question Title

* 20. Title:

Question Title

* 21. Address 1:

Question Title

* 22. Address 2:

Question Title

* 23. CIty, State  Zip

Question Title

* 24. Email:

Question Title

* 25. Phone Number: 

T