Dr. Rogers Prize™
For Excellence in Complementary & Alternative Medicine
http://www.drrogersprize.org/
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Step 1 of 3: Intent to Nominate

The Intent to Nominate form must be completed in order to provide accurate and current contact information for both the nominator and nominee. The information on this form will be automatically associated with each document in your package and will enable us to better assist you throughout the nomination process.

Important Dates:

The Intent-to-Nominate form can be submitted up to the close of nominations at 5:00 pm (PST) on Friday, November 16, 2018. For a chance to win the VIP Package of four tickets to the 2018 Dr. Rogers Prize Award Gala, submit this form prior to April 15th 5:00 PM (PST).

Note: All form fields are required except where noted as optional.

Intent To Nominate:

I am pleased to provide notice of my intention to complete and submit a Nomination Package for the Dr. Rogers Prize in the name of the following Nominee:

Nominee Information
Nominee First Name:
Nominee Last Name:
Company/Institution:
Title:
Country:
Street Address:

This address will be used for all post/courier correspondence regarding the Dr. Rogers Prize.
City:
Province/State:
Postal/ZIP Code:
Home Phone:
Office Phone:
Cell Phone:
(optional)
Email Address:
Confirm Email:
Please type the email address twice in the spaces above to confirm.
Website/Blog:
(optional)
Nominator Information
Nominator First Name:
Nominator Last Name:
Company/Institution:
Title:
Country:
Street Address:

This address will be used for all post/courier correspondence regarding the Dr. Rogers Prize.
City:
Province/State:
Postal/ZIP Code:
Home Phone:
Office Phone:
Cell Phone:
(optional)
Email Address:
Confirm Email:
Please type the email address twice in the spaces above to confirm.
Website/Blog:
(optional)

Upon submission of this form, the nominator and nominee will each receive an email containing a unique Access Code specific to the nomination. Please save this code as it is required to gain access to your Nomination Package.

Should you require more information or assistance completing the forms, please contact the Dr. Rogers Prize Coordinator.

Please wait while your submission is processed.