Resident Award of Excellence

Michael L. Madden, MD Resident Award of Excellence
Nomination Form

Residency Program Information

Name of Person Completing Form: *

Residency Program Name *

Address *

City *

State *

Zip Code *

Nominee Information

AAFP ID# *

First Name *

Last Name *

Designation *

Address *

City *

State *

Zip Code *

Email address *

Cell Phone Number *

Completion Date of Residency: *

Please describe how the resident exhibits the following criteria:

How has the resident shown evidence of active student leadership in family medicine activities? *

How has the resident participated in family medicine activities at the state or national level? *

How has the resident shown scholarly accomplishments in his/her residency by the development of a research project or publication of a scientific paper? *

Please upload the following documents before submitting this form:

A high resolution professional head shot *

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A short bio of the nominee *

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Current curriculum vitae (limited to three pages) *

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Letter of recommendation from the faculty of the residency program or an LAFP active member *

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Supporting Documentation: (Maximum of eight pages of supporting documentation)

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