2022 OMA Awards Nomination Form

Award Category:

Nominator Name:

Nominator Phone:

Nominator Email:

Nominee's Name:

Nominee's Phone

Nominee's Email

Nominee's Address:*

Address Line 1

Address Line 2

City

Province

Postal Code

Date of Birth:

Specialty (if applicable):

Please complete the rest of the form, keeping in mind the Criteria of the Award for which the Nominee is nominated.

Current Position(s) and Appointments:

Description of Involvement in CMA / OMA Constituencies / Medical Schools / Hospitals / Community Activities (whichever is applicable to the criteria of the Award):

Professional Memberships (e.g. associations):

Descriptions of qualification and attributes in relation to the award being nominated for

Please upload any other supporting documents

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For further information, please contact us at omaawardnominations@oma.org.