2008 MHA Health Care Leadership Award
Nomination Form

Name of nominee: (specify Mr./Mrs./Ms., MD/DO)
Last Name
Address
Address (cont.)
City
State
ZIP
E-mail *Required
Fax
By providing your fax number, you agree to receive facsimile advertisements from the MHA.
Business Affiliation
Position
Name of chief executive officer (or board chair if nominee is a CEO) supporting nominee:
Last Name
Address
Address (cont.)
City
State
ZIP
E-mail *Required
Fax
By providing your fax number, you agree to receive facsimile advertisements from the MHA.

Describe Nominee's Organizational Contributions: (See criteria section):

Describe Nominee's Community Contributions: (See criteria section):

Appointments/affiliations: List current and previous appointments/affiliations, such as medical staff, governing boards, education, United Way, etc. (with dates, positions held, etc.)

      

This form may be submitted electronically, with supplemental materials e-mailed to Clark Ballard by 11:59 p.m. Aug. 7, 2008. Alternatively, this form may be printed, completed and mailed with supplementary materials to the following address or faxed to (517) 327-4506. Materials, including the nomination form, should not exceed five pages and should arrive at the MHA by 11:59 p.m. Aug. 7, 2008. 

MHA Health Care Leadership Award
Michigan Health & Hospital Association
Attn: Clark Ballard
6215 West St. Joseph Highway
Lansing, MI  48917