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* 1. MAG Award

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* 2. Nominating CMS or Nominating Member Physician's Name

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* 3. Nominator's Phone

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* 4. Nominator's Email

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* 5. Nominee

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* 6. Nominee's Practice or Employer (enter “N/A” if not applicable)

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* 7. Nominee’s Specialty (enter “N/A” if not applicable)

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* 8. Nominee’s Medical School (enter “N/A” if not applicable)

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* 9. Nominee’s City of Residence

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* 10. Nominee’s Phone

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* 11. Nominee’s Email

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* 12. Nominee’s Principal Professional Membership and Faculty Appointments

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* 13. Nominee’s Principal Honors

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* 14. Nominee's Contribution to the Medical Profession (i.e., career highlights or professional accomplishments)

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* 15. Sponsor’s Narrative Statement (i.e., why the nominee deserves the award – maximum of 500 words)

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* 16. Supplemental Attachments

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