Your Name

Your Email

Your Phone Number

Name of Nominee

Professional Title/Organization

Email of Nominee

Phone Number of Nominee

Examples of why the person is worthy of the award. Descriptions should be no more than 200 words.
Criteria for the selection of the award include:
• Exemplary leadership and diligence in promoting public health;
• Remarkable contributions and support in fostering public health programs; and
• Work or actions that have impacted the community’s health in a positive way.