Dean's Alumni Awards Nomination Form | Temerty Faculty of Medicine

Nominee Information

Nominee's Full Name*

* Degree(s) and Year(s) of Graduation*

* received from, or training completed at, U of T's Faculty of Medicine (now the Temerty Faculty of Medicine)

Department(s)*

I wish to nominate this person for the following award:*

Lifetime Achievement

Impact (non-MD research and health science education alumni)

MAA MD Alumni of Distinction (MD and MD/PhD alumni)

Humanitarian

Emerging Leader (alumni who have completed training in the last 15 years)

Has the nominee been made aware of this nomination?*

Yes, the nominee is aware of this nomination

No, the nominee is not aware of this nomination

Nominee's Street Address

City/Town

Province/State

Postal Code/Zip

Country

Phone Number

Email Address*

Nomination Package – Supporting Documents

Chair/Director Support (if nominee is current faculty)

If the nominee is current U of T faculty, please confirm that the chair/director of the appropriate department, division, centre, etc. supports this nomination.

Chair/Director Name and Title

Nominator's Reference:*

Please provide a summary (max. 250 words) about why you think the nominee should receive the award and how their work meets the outlined criteria. Letters must explain the short- and long-term impact of the nominee's work.

Letter of Support*

Please attach an additional letter of support. This letter must be from an additional individual familiar with the nominee's work (this person is different from the nominator).
One file only.
20 MB limit.
Allowed types: txt, rtf, pdf, doc, docx.

Nominee's CV/Resume*

Please attach the most recent version of the nominee's CV or resume.
One file only.
20 MB limit.
Allowed types: txt, rtf, pdf, doc, docx.

Additional Information

Please include any additional information that you think is relevant to the nomination (select publications, journal abstracts, media coverage, etc.) A maximum of two documents can be attached but only one document per attachment. Please note that if more than one document is submitted in an attachment, only the first one will be reviewed. If you are attaching an article, please only include the abstract. We ask that attachments do not exceed five pages.
Maximum 2 files.
20 MB limit.
Allowed types: txt, rtf, pdf, doc, docx.

Nominator Information

Nominator's Full Name*

Employer

Title/Position

Relationship to Nominee*

How long have you known the nominee?*

Nominator's Street Address*

City/Town*

Province/State*

Postal Code/Zip*

Country*

Phone Number*

Email Address*

How did you hear about the Dean's Alumni Awards program?*