2021 Family Physician of the Year Nomination Form Please enable JavaScript in your browser to complete this form.Nominee's Information (click the button at the bottom to submit!)Physician's Name *FirstLastPhysician's home address (submit as much as you know)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhysician's business address (submit as much as you know)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone (home or cell) *Phone (business) *Fax (if applicable)Email *Is the nominee a WAFP member? *YesNoYour InformationYour Name *FirstLastYour Email *Your PhoneAdditional InformationWashington Academy of Family Physicians 1239 120th Ave. NE, Suite G Bellevue, WA 98005 info@wafp.net Fax: 425-747-3109 Nominations must be received by Jan. 29, 2021 In your letter, please describe how the physician nominee exhibits the following criteria: Provides their patients with compassionate, comprehensive and caring family medicine on a continuing basis. Is directly and effectively involved in community affairs and activities that enhance the quality of their community. Provides a credible role model professionally and personally to their community, to other health professionals, and to residents and medical students. Can effectively represent the specialty of family medicine and the WAFP in public speaking. What characteristic makes this person stand out among their colleagues? Nomination Requirements Completed nomination form Current curriculum vitae Supporting Documentation Maximum of eight pages: If more than eight pages of supporting documentation are received, only the first eight pages will be used. (The nomination form and CV do not count against this total.) If submitting electronically, please scan the nomination form and all supporting documentation to one PDF file. If submitting a hard copy, please do not reduce more than two letters to a page; provide pages of photocopy-ready and reproducible quality; and do not fold materials when mailing. Is your PDF (including letters of recommendation and nominee's CV) ready to upload?YesNoLet's do it! Use the field below to upload your documentation: Click or drag a file to this area to upload. This is the Button to Click to Submit Contact Information!
