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Employer of Excellence Awards
NOMINATION FORM
My Contact Details
First Name
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Last Name
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Title
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Organization Name
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Email Address
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Type of Organization
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Please choose one
Academic medical center
Certified Rural Health Clinic
College or university
Community Health Clinic
Convenient Care (including retail clinics)
Federally Qualified Health Center
Government
HMO
Hospice
Hospital
Medical staffing agency
Other healthcare-related corporation
Physician practice: Multispecialty group
Physician practice: Single specialty group
Physician practice: Solo practice
Type of Corporation
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Nomination Statement
Why are you are nominating your employer for the 2020-2021 CHLM Employer of Excellence Awards? Please give specific examples of why this employer is an excellent place for PAs to work. Refer to the
award criteria
to identify areas of relevance.
*
1,000 characters limit
Employer Information
We will be notifying your employer of this nomination and encouraging them to apply for the Employer of Excellence Award. Please provide the contact details of up to three administrator(s) who may be interested in learning about this award opportunity and/or likely to be involved in the award application process for your organization.
Primary Administrative Contact
First Name
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Last Name
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Title
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Phone Number (Please enter only digits.)
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Email Address
*
Secondary Administrative Contact
First Name
*
Last Name
*
Title
*
Phone Number (Please enter only digits.)
*
Email Address
*
Tertiary Administrative Contact
First Name
Last Name
Title
Phone Number (Please enter only digits.)
Email Address
Employer of Excellence Awards