HCLM Nominating Organization Form - North Carolina Medical Society

HCLM

Step 4: Nominating Organization Endorsement Form

(To be completed by the county society, specialty society, hospital, medical practice, health care organization or NCMS)

Please Complete:

Step

Name of Nominee*

Nominating Organization Name*

Name of Person Completing Form*

Title of Nominator*

Phone*

Email Address*

Please describe why you believe the nominee should be selected by the Kanof Institute for Physician Leadership Advisory Board for participation in the upcoming HCLM program. Please include interactions with the nominee that demonstrate leadership capabilities and/or potential.

Your comments (limit 1000 characters)*

To the best of your knowledge, is this person a respected clinician in his/her community?

Explain.

By checking the box below, I certify that I am fully supportive of the nominee's participation in this program and that the information above is true to the best of my knowledge.

I agree.*

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