Laureate Nomination Form
Nominee Details
Title:
Dr.
Mr.
Mrs.
Ms.
Other
First Name:
Last Name:
Is the nominee a Canadian citizen?
Yes
No
Is this a posthumous nomination?
Yes
No
Contact Information of Nominee or Next-of-Kin for posthumous nominations
Title:
Dr.
Mr.
Mrs.
Ms.
Other
First Name:
Last Name:
Relationship to Nominee (for posthumous nominations only):
Position (if applicable):
Department (if applicable):
Business Name (if applicable):
Business Address:
Business Phone:
Home Address:
Home Phone:
Email Address:
Nomination Category
Builder (Innovative Leadership)
Excellence in Health Care
Excellence in Health Research
Basic Research
Clinical Research
Health Services
Population & Public Health
Citation
Please state in 3-4 sentences (maximum 250 characters) the contribution(s) made by this nominee that justifies his/her induction.
(Maximum characters: 250)
You have
characters left.
Contact Information of the Principal Nominators (for nominations made by individuals)
If this nomination is being made by an organization, skip to the next section.
Nominator 1
Title:
Dr.
Mr.
Mrs.
Ms.
Other
First Name:
Last Name:
Position (if applicable):
Department (if applicable):
Business Name (if applicable):
Business Address:
Business Phone:
Home Address:
Home Phone:
Email Address:
Nominator 2
Title:
Dr.
Mr.
Mrs.
Ms.
Other
First Name:
Last Name:
Position (if applicable):
Department (if applicable):
Business Name (if applicable):
Business Address:
Business Phone:
Home Address:
Home Phone:
Email Address:
Contact Information of the Organization (for nominations made by an organization)
Organization Name:
Contact Person’s Title:
Dr.
Mr.
Mrs.
Ms.
Other
First Name:
Last Name:
Position (if applicable):
Department (if applicable):
Business Address:
Business Phone:
Email Address:
Addtional Requirements
Before your nomination is complete you are required to attach further documentation to support the nomination. All documents must be provided in PDF format.
Mandatory Documents
Nomination Letter(s):
a) For nominations made by two individuals, submit either one letter (signed by both nominators) OR two letters (each signed by a nominator)
b) For nominations made by an organization, only one letter is required
(if applicable)
Curriculum Vitae or Biography of Nominee
Optional Documents (Maximum of 8 pages)
Letters of Support
Other Material (such as news & journal articles)
(if applicable)
(if applicable)
(if applicable)
(if applicable)
(if applicable)
(if applicable)
(if applicable)
(if applicable)