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2011 Sérgio Arouca Award
 
     
 

The 2011 Sérgio Arouca Award for Excellence in Universal Health Care Nomination Form

The 2011 Sérgio Arouca Award for Excellence in UniverBefore 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 and
a letter of support (two-page limit) from an official representative of the nominee organization, the PAHO/WHO representative (PWR) of the country of the nominee or an official representative of the ministry of health of that country (two-page limit), and a curriculum vitae of the nominee if an individual or an organization profile if an organization. The letter of support must come from someone other than the nominator. 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  
  Nominated Program or Institution Information
 
  Program name *
  Institution’s name *
  Address *
  City *
  State or province *
  Country *
  Telephone number *
  E-mail address *
  Website
  Year established *
  Type of institution *
  Annual budget *
  Program or Institution Contact Information
  Contact person’s name *
  Title *
  Current position *
  Address *
  City *
  State or province *
  Country *
  Telephone number *
  E-mail address *
  Nominated Individual Information
  (only complete if an individual is being nominated)
  Name of the individual *
  Title *
  Current position *
  Institute *
  Address*
  City *
  State or province *
  Country *
  Telephone number *
  E-mail address *
  Website
  Nationality *
  Specialty *
 
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