The Freeman Andrus Award: Nomination Form

Complete the form below to nominate someone for The Freeman Andrus Award. Remember that submissions are due May 31, 2015!

Freeman Andrus Award

Fields marked with an * are required

for the Freeman Andrus Award.

Nominator's Contact Information
(Your Information)

Nominee's Contact Information
(Information about the person you're nominating)

Tell us why this nominee should be considered for the Freeman Andrus Award

Please answer the following questions as they pertain to your nominee named in this official nomination form.

I, the nominator, give my consent to:

  • Use the information stated in this nomination form for presentation purposes if the person who I have nominated is selected for the Freeman Andrus Award
  • Contact the nominee if he/she is selected for the Freeman Andrus Award as a runner-up, or winner, and to let them know that I nominated him/her
  • Stating that all of the information contained in this nomination form is true to the best of my knowledge, and that both the nominee and myself have attained the minimum age of 19 (nineteen) to submit this application for consideration.
  • MDAO
  • CMHA
  • St. Joseph's Healthcare Hamilton