The Wisconsin Medical Society is asking the people of Wisconsin to nominate physicians for this honor. The Physician Citizen of the Year Award recognizes physicians who volunteer their time and talents to help others through cultural, civic or charitable efforts and events. Please use the form below to tell us about a physician you think is worthy of the Wisconsin Medical Society's Physician Citizen of the Year award.

Here are the requirements:

• The physician must be a Wisconsin resident.
• The physician must be an MD or DO.
• Except in unusual circumstances, the service to the community should be uncompensated.
• Previous winners of the award are not eligible. (You will be notified if your nominee is a previous winner.)

Nominee Information:

Nominee Name:

Clinic/Hospital/Office:

Address:

City:

State:

Zip:

Questionnaire:

Why do you believe the nominee should be named the Physician Citizen of the Year?:

Can you give some specific examples of the extraordinary efforts the doctor has done for the community? (community projects, public offices, participation in civic service and charitable organizations, etc.):

This nomination was made by:

Your Name:

Your Address:

Your City:

Your State:

Your Zip:

Your Phone Number (please add area code):

Your E-mail Address: