GAPA Annual Awards Nomination Form

Please complete all of the fields below and click submit.

I nominate the following individual for a GAPA Award:

Nominee Name:
Nominee Address 1:
Nominee Address 2:
Nominee City:
Nominee State:
Nominee Zip:
Nominee Telephone (if known):
Nominate for:
  PA of the Year
  Humanitarian of the Year
  Rural PA of the Year
  Dylan Maples Scholarship
  Distinguished Service Award
  Physician of the Year
  Physician/PA Partnership Award
  Student Intern of the Year
Nominator Name:
Nominator Email Address:
Nominator Mailing Address 1:
Nominator Mailing Address 2:
Nominator City:
Nominator State:
Nominator Zip:
Please provide a summary statement describing your nominee's attributes and reasons considered for special recognition. Please limit your statement to a maximum of 150 words.

The deadline for receiving nominations is June 15.
If nominating in more than one category, please submit an additional form.