Entry/Nomination Form

Nominations for the AMA (WA) Junior Doctor of the Year (Dr Camille Michener Legacy Award) can be completed online, or you can download the PDF version of the form.

  • Section A: Your Details

  • Section B: Nominee's Details

    Please provide details of the Doctor in Training you are nominating below.
  • Section C: Supporting Documentation

  • Supporting material addressing the criteria to be attached.

  • (a) Questions Addressed

    • Provide a short statement of who is to be nominated and why? (Max 150 words)
    • Provide a statement as to how the nominee has provided outstanding service/performance within the Medical Profession and the Community. The demonstration can be in areas such as:
      • Teaching and Education
      • Leadership and Advocacy
      • Doctors' Wellbeing
      • Community Service
      • (Max 1,500 words)
    • Describe the intended use of the $3000 prize money if successful. The expectation of the Award Selection Panel is that the prize money will be used for ongoing professional devlopment. (Max 200 words)
    • Note: If you are nominating another person, the AMA (WA) will contact your nominee for this information

  • (b) Supporting Materials

      To support the entry, it is allowable for the following information to be attached:

      • Testimonials/References
      • Newspaper/Media Clipping
      • Promotional material such as flyers, brochures, manuals that may have been developed.
  • Section D: Attached Documentation

  • Accepted file types: doc, docx, pdf.
  • Accepted file types: doc, docx, pdf.
  • If the document is too large to attach please forward by post or email clearly identifying the Nominee.
    Post: Private and Confidential
    The Chairperson
    AMA (WA) Junior Doctor of the Year 2018
    c/o AMA (WA)
    PO Box 133
    Nedlands WA 6909
    Email: Renee.Hay@amawa.com.au
  • Section E: Declaration by Proposer