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