Outstanding Humanitarian Contribution Award

Nominations for 2024 Nicholas M. Greene, M.D. Outstanding Humanitarian Contribution Award

Nominations must be received no later than April 30, 2024.
Name of Nominee*
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Undergraduate Training*
Years*
Degree*
Medical School*
Years*
Degree*
Internship – Institution
Type
Years
Residency – Institution*
Type*
Years*
Honorary Degrees:
Institution
Degree
Institution
Degree
Institution
Degree
Honorary memberships and awards (give details as to type and year received):
Membership in professional societies and organizations (give name of organization(s) and year nominee became a member):
Brief statement as to why nominee should receive award at this time (additional materials may be attached):*
For component society nominations:
By
President
Date

MonthDayYear
Date
By
Secretary
Date

MonthDayYear
Date
For nominations by an ASA member:
By
ASA Member
Date

MonthDayYear
Date
Attach the following documents or email the documents directly to Angelica Batha at a.batha@asahq.org.
- One letter of support
- One updated CV
- Statement that the nominee is willing to be considered
- Documentation of International Involvement, which should not exceed 5 pages
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Nominations for 2024 Nicholas M. Greene, M.D. Outstanding Humanitarian Contribution Award