Jun 30, 2015 - Fax: Email: In 500 words or less, please indicate on the following page ... to accommodate your typing if
2015 Nomination Form
T. REGINALD HARRIS, MD MEMORIAL AWARD Submission Deadline: Tuesday, June 30
Nominee: Organization: Address: Phone:
Fax:
Email:
Fax:
Email:
Nominator: Organization: Address: Phone:
In 500 words or less, please indicate on the following page why you have nominated this physician and how he or she demonstrates the tradition of service to the medical community. Provide examples of his or her commitment to quality health care that were exemplified by the life and career of T. Reginald Harris, MD. Attach extra pages as needed. Please do not submit CVs.
Please email, fax, or mail your nomination form to Chris Pfitzer by Tuesday, June 30, 2015. Email:
[email protected] • Fax: 919.461.5700 • Phone: 800-682-2650, ext. 5687 The Carolinas Center for Medical Excellence 100 Regency Forest Drive, Suite 200, Cary, NC 27518 www.thecarolinascenter.org/HarrisAward
Please note that the box below will expand to accommodate your typing if the information is filled in electronically.
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