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:

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

The North Carolina Medical Society

Physical Address:
222 N. Person Street
Raleigh, NC 27601
Get Directions
800.722.1350 (NC only)
919.833.2023 FAX
Mailing Address:
PO Box 27167
Raleigh, NC 27611


Medical Mutual

The NCMS is a proud partner with
Medical Mutual.