NOMINATION FORM
THE RICHARD S. HODES, M.D.
HONOR LECTURE AWARD
2009
Deadline for Submittal is June 30, 2008
The Commission encourages electronic submission of all the materials with exception of the letters of support.
Submit nominations to:
Awards Committee
c/o Ted Buckner, Associate Director
Southeast Compact Commission
21 Glenwood Avenue, Suite 207
Raleigh, NC 27603
Phone: (919) 821-0500
Fax: (919) 821-1090
Email: secc@secompact.org
Nominee's Information
Name of Nominee_______________________________________________________
Present Position/Exact Title________________________________________________
Company/Organization/Institution____________________________________________
Address_______________________________________________________________
City____________________________ State_______ Zip Code___________________
Phone__________________________ E-mail_________________________________
Citation
Provide a brief statement, not to exceed 100 words, giving the major innovation(s) for which the nomination is being made.
Basis for Nomination
Please include a statement, not to exceed 750 words, on why the innovation is deserving of special recognition.
Support Letters
Submit by U.S. Mail or courier no more than three brief supporting letters from colleagues, peers or former students. Please do not attach exhibits, samples, etc. Voluminous materials are not useful to the selection committee.
Nominator Information
Name________________________________________________________________
Present Position/Exact Title________________________________________________
Company/Organization/Institution____________________________________________
Address_______________________________________________________________
City___________________________________ State/Province___________________
Zip/Postal Code_______________ Country______________
Business Phone___________________ Fax______________________
E-mail Address____________________________________________
Signature_________________________________________________
Date________________________________