LECTURE AWARD NOMINATION FORM Please complete all fields below and click Submit to enter your nomination. When you click Submit, a link to print a PDF will be generated on the next page. Please click the link and download the PDF for your records. Deadline is JANUARY 15. NOMINATOR(person submitting the nomination)Name First Last Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneNOMINEE(person being nominated)Name First Last Email* Phone*University where Nominee was inducted into The Rho Chi SocietyNominee’s Education (degree, discipline, date, institution)Brief Summary of Nominee’s Noteworthy Contributions to the Health ProfessionsBrief Summary of Nominee's Research and Scholarship InterestsNominee’s Relevant Honors and AwardsEndorsers of the NominationEmailThis field is for validation purposes and should be left unchanged.