FCIHR Distinguished Service Award
Nomination Form
FCIHR DISTINGUISHED SERVICE AWARD
Presented in recognition of significant contributions to the mission of FCIHR
Friends of the Canadian Institutes of Health Research shall, from time to time, recognize
exceptional contributions of members of the association who have advanced the mission and
goals of FCIHR. Nominations will be solicited from the membership and the awardee will be
selected by an awards committee appointed by the Board of Directors. The award will be in
the form of a plaque bearing a citation and will be presented to the Honouree at any one
of several events, including the Ottawa Evening, the Annual Meeting, or other appropriate
public venue.
| Nominator | ___________________________ | Nominee | _______________________________ |
| Organization | ___________________________ | Organization | _______________________________ |
| Address | ___________________________ | Address | _______________________________ |
| ___________________________ | _______________________________ | ||
| City | ___________________________ | City | _______________________________ |
| Province | ___________________________ | Province | _______________________________ |
| Postal Code | ___________________________ | Postal Code | _______________________________ |
| Phone | ___________________________ | Phone | _______________________________ |
| Fax | ___________________________ | Fax | _______________________________ |
Reason for Nomination: (please use additional pages)
Please submit this form and the Nominee’s résumé to:
Awards Committee, Friends of CIHR
GG441 Health Sciences Centre, 820 Sherbrook Street, Winnipeg, MB R3A 1R9
tel: (204) 787-3794 fax: (204) 787-3279
e-mail: fcihr@fcihr.ca