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Gold Cystoscope Award Nomination Form

American Urological Association
2014 Gold Cystoscope Award Nomination Form

For nominations submitted by Urology Chairs and Program Directors

The Gold Cystoscope Award may be presented annually to a urologist who has distinguished him/herself by outstanding contributions to the profession within ten (10) years of completing residency training (residency must be completed no earlier than June 2004). Sponsor: Olympus.

Directions:

Please complete each section of this form in its entirety and attach an abbreviated CV (no more than 3 pages in length). Only nominations received from Urology Program Chairs & Directors will be accepted. Questions regarding the nomination process may be directed to Nancy Waid, AUA Committee & Society Affairs at nwaid@AUAnet.org.

Deadline to receive nominations is October 31st

Nominee (First Name, Middle Initial, Last Name):

Year Completed Residency:

Nominee's Current Institution:

City/State:

Nominee's CV:

Please summarize the reason for this individual's nomination for this award (500 words or less):

 

Your Name:

Your Title:

Your Institution:

If you would like us to send confirmation that this nomination was received, please provide your email address:

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