Award Nomination Form

Nomination Deadline: September 18, 2017

 The Lester Brown Award
 The Gerald S. Gussack Memorial Award
 
Nominee Name:
Address
City, State, Zip:
Phone Number:
Email Address:
 
How many years has this physician been in practice in Georgia? 
  Check here if the nominee is an Otolaryngologist/Head & Neck Surgeon.
(The nominee does not necessarily have to be an Otolaryngologist.)
 
Please state why you think this individual is deserving of this award.
 
Your Name:
Your Phone Number:
Your Email: