2022 Rural Practitioner of the Year Nomination Form

Nominee Information

The Rural Health Practitioner of the Year Award recognizes a direct service provider for leadership in bringing health services to rural populations. This award is meant to be inclusive of all health disciplines (e.g. dentistry, optometry, nursing, etc.). Factors taken into consideration include providing outstanding care, involvement in the community, and lasting contributions to the health care system.

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* 1. Nominee Information

Name

Title

Email Address

Phone Number

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* 2. Nominee Current Organization

Organization Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 3. Rural Geographic Area(s) affected by nominee’s work

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* 4. Nominee Resume/CV

Please upload nominee's resume or CV. If you do not have a copy of their resume/CV, please enter education and professional history below.

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

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* 5. Nominee’s Educational Background (skip if resume/CV uploaded)

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* 6. Nominee’s Work Experience (skip if resume/CV uploaded)

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* 7. Nominee’s contribution to rural healthcare.

Please attach a word or PDF document with a 300-500 narrative describing the nominee’s involvement in rural health, the significance to his/her contribution to rural health, and how the rural area and residents have benefited from the contribution.

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

Choose File