PAHEF - Nomination Form

2011 Abraham Horwitz Award

The 2011 Abraham Horwitz Award for Excellence in Leadership in Inter-American Public Health Nomination Form

Before completing this nomination form, please be sure that you have read and understand the award guidelines. Please ensure you complete all the required fields in your application.

Instructions: Please fill in all the requested information on the nomination form and attach a letter of nomination (two-page limit) signed by the nominator, a letter of support (two-page limit) signed by an individual other than the nominator and preferably from a country other than that of the nominee, and curriculum vitae of the nominee. Unfortunately, we are unable to consider unsigned documents.

To be considered, please ensure that you have completed and submitted the online nomination on or before the closing date of the call.

All items marked with an asterisk (*) must be completed.
Note: You must click the “Save” button at the bottom of each page to save your responses.

If you have questions about completing this form, contact

STEP 1 of 4


	Nominee Information

	Name of the nominee *

	Title *

	Current position *


	Address *

	City *

	State or province *

	Country *

	Telephone number *

	E-mail address *

	Website

	Nationality *

	Specialty *


	Academic Degrees

	(Please list in reverse chronological order)
	Degree, Name of university, Year of graduation

	* 1.

	2.

	3.

	4.


	Recent Professional Experience

	(Please list in reverse chronological order)
	Title, Organization, Years

	* 1.

	2.

	3.

	4.