Emergency Medicine Residents’ Association



Emergency Medicine Residents’ Association

Medical Student Governing Council

Nomination Form for the Emergency Medicine Interest Group Advisor Certificate of Appreciation

The EMRA Medical Student Governing Council EMIG Advisor Certificate of Appreciation is an opportunity to recognize an emergency physician at your institution that has demonstrated outstanding, selfless and sustained service to your medical student Emergency Medicine Interest Group. The recipient receives a certificate and letter that is also sent to the physician’s Department Chair. Certificates will be mailed on or around May 1.

Please complete the following form and mail, fax (972.580.2829), or email (emra@) it by April 1 to:

EMRA

4950 W Royal Lane

Irving, TX 75063-2524

Nominator Information

Name: _________________________________________

Address: _________________________________________

City/State/Zip: _________________________________________

Phone: (____)______________

E-mail: _________________________________________

Medical School: _________________________________________

Certificate Recipient Information

Name: _________________________________________

Title: _________________________________________

Address: _________________________________________

City/State/Zip: _________________________________________

Phone: (____)______________

Department Information

Department Chair Name: _________________________________

Address: _________________________________________

City/State/Zip: _________________________________________

Phone: (____)______________

In the remaining space or on an attached sheet, please tell us how this physician has contributed to the success of your Emergency Medicine Interest Group:

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

Questions about how to fill out this form? E-mail us at emra@

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download