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 DetailsName*Position Held*Current Place of Employment*TelephoneEmail Address Street Address City State / Province / Region ZIP / Postal Code Section B: Nomination DetailsPlease provide details of the Doctor in Training you are nominating below.Nominee's NamePosition HeldCurrent Place of EmploymentAddress Street Address City State / Province / Region ZIP / Postal Code PhoneEmail Section C: Declaration by ProposerI confirm the information contained in this entry is, to the best of my knowledge, true and correct.* Confirmation Section D: Information to be AddressedSupporting material for your nomination can be sent by post or email with the name of the person nominating clearly marked: Post: PO Box 133, Nedlands WA 6909 Email: Mary.Waldron@amawa.com.au Alternatively you can include up to 2 documents below (please use Microsoft Word or Adobe PDF). 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 in each of the following categories: Teaching and Education Leadership and Advocacy Doctor's Wellbeing and Community Service (Max 1,500 words) Describe the intended use of the $3000 prize money if successful (Max 200 words) Note: If you are nominating another person, the AMA (WA) will contact your nominee for this information Section E: Supporting Material Questions AddressedAccepted file types: docx, pdf, doc.Supporting MaterialAccepted file types: doc, docx, pdf.