* 1. Please select the award for which you are nominating:

* 2. Name and address of nominee or program: (If program, identify director)

* 3. A brief description of nominee's achievements, contributions, and/or service to rural care: 

* 4. Personal and/or professional association with the nominee: (First-hand knowledge of achievements)

* 5. Additional information which should be considered by the awards committee: 

* 6. Nominator name and contact information: