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: Nomination Details

    Please provide details of the Doctor in Training you are nominating below.
  • Section C: Declaration by Proposer

  • Section D: Information to be Addressed

  • Supporting material for your nomination can be sent by post or email with the name of the person nominating clearly marked:

    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

  • Accepted file types: docx, pdf, doc.
  • Accepted file types: doc, docx, pdf.