2024 APGO Humanism in Teaching Award Nomination Form

RECIPIENT INFORMATION
Please enter the recipient's information EXACTLY as it should be printed on the award certificate.
Recipient's First Name:*
Recipient's Last Name:*
Recipient's Suffix (MD, DO, PhD, etc.)*
Academic Rank/Department:*
Institution:*
Brief narrative of 250 words or fewer about nominee and why they are deserving of this award:*
NOMINATOR INFORMATION
Department Chair's (Or Authorized Person) First Name:*
Department Chair's (Or Authorized Person) Last Name:*
Department Chair's (Or Authorized Person) Title:*
Department Chair's (Or Authorized Person) Email:*
MAILING INFORMATION
Mail award certificate to:
Name:*
Institution or note that this is a Home Address:*
Address:*
Address 2/Suite #:
City:*
State (Two-Letter Abbreviation):*
Zip:*
Email*
Please double check that ALL information is accurate and spelled correctly before submitting.

Upon receipt of this application, APGO will supply each Department or Institution with an award certificate. Institutions may determine their own method of presentation.

Please Note: Certificates are shipped via the United States Postal Service (USPS). Please allow four to six weeks for receipt. If necessary, contact APGO Admin, upon submitting your nomination to discuss options for expediting your shipment.

RECIPIENT INFORMATION