APGO Donna Wachter Clerkship Coordinator Award Nomination Form (2024)

Date*
MM slash DD slash YYYY
Institution:*
Department Chair Information
Department Chair's First Name:*
Department Chair's Last Name:*
Department Chair's Suffix:*
Department Chair's Email:*
Department Chair's Phone Number:*
Nominee Information
The nominee must be employed as an Ob-Gyn Clerkship Coordinator for a minimum of five years at the nominating department/institution to be eligible for this award.
Nominee's First Name:*
Nominee's Last Name:*
Nominee's Suffix:
Nominee's Email:*
Nominee's Phone Number:*
Award Administrator Contact Information
(for all communications regarding this award)
Award Administrator Contact First:*
Award Administrator Contact Last:*
Award Administrator Contact Suffix:
Award Administrator Contact Email:*
Award Administrator Contact Phone Number:*
Upload Section
Department Chair Letter of Recommendation*
Max. file size: 50 MB.
Ob-Gyn Faculty Letter of Recommendation (1 of 2)*
Max. file size: 50 MB.
Ob-Gyn Faculty Letter of Recommendation (2 of 2)
(if applicable)
Max. file size: 50 MB.
Nominee's Resume*
Max. file size: 50 MB.
Additional Information (if needed)
Max. file size: 50 MB.
Headshot of Nominee*
Max. file size: 50 MB.
*Required for first-time nominations
(to be used in announcements about the award)
· High-resolution professional headshot
· JPEG Format

Department Chair Information