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________________________________