Nominate a doctor

You may either download a nomination form or complete this form online.

PDF nominations can be forwarded to RWAV via email to samantha.marnell@rwav.com.au, by fax to (03) 9820 0401 or posted to 2010 Victorian Rural Doctors’ Awards, PO Box 7382 St Kilda Road, VICTORIA 8004 and must be received by COB Friday 30 July 2010.

Partially completed nominations will be deemed invalid and will not be considered by the Awards Selection Panel.


Personal Details
Title:
First name:*

  		Last name:*

 
E-mail:*  

  		Phone:*

 
Mobile:

 		 Relationship to nominee:*

 


Postal address:
Street address:*

  		Town/Suburb:*

  		State:

 		 Postcode:

 



Personal Details
Title:
First name:*

  		Last name:*

 
Phone:*

  		E-mail:  
Length of service:

 		 Length of rural service:

 
Total in rural Victoria:

 		 Spouse name (if known):

Please note, the awards are presented to doctors and their spouse/family
Medical field:*

 		Currently in practice:*


Practice details
Practice name:*

 
Street address:*

  		Town/Suburb:*

  		State:

 		 Postcode:

 



Award category