RUSM ALUMNI ASSOCIATION AWARDS - ALUMNI LEGACY AWARD - 2021

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* 1. NOMINATOR'S INFORMATION:

First Name:

Last Name:

Phone Number:

Email Address:

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* 2. Are you an alumna/us of RUSM?

Yes

No

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* 3. If so, what is your graduation year?

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* 4. What is your relationship to the nominee?

Spouse/Partner

Relative

Current Colleague

Classmate

Friend

Other (please specify)

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* 5. NOMINEE'S INFORMATION:

First Name:

Last Name:

Graduation Year:

Email Address:

Phone Number:

Current Hospital/Practice:

Current Position:

Current Specialty:

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* 6. Please provide your nominee's professional, societal or communal recognition

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* 7. How has your nominee contributed to the advancement of the medical profession?

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* 8. Is there anything else about your nominee that you would like the committee to consider?