Life Member Nomination Form

Nominee Information

Name*

First Last

Company*

Title

Preferred Address*

Street Address Address Line 2 City State ZIP Code

Phone Number

Email Address*

Nominator Information

Name*

First Last

Company*

Title

Preferred Address*

Street Address Address Line 2 City State ZIP Code

Phone Number

Email Address*

How long has the Nominee been a member of CMIA?*

(Requirement of at least 10 years)

What roles has the Nominee held in CMIA?*

What impact has the Nominee made on CMIA?*

What impact has the Nominee made on the biomed community?*

What words of advice would the Nominee give to the biomed community?*

Up to 3 (three) Letters of Recommendation can be submitted using the upload form below.

Letters of Recommendation

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 10 MB, Max. files: 3.

Allowed file formats: .doc, .docx, or .pdf (no larger than 10mb in size)

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Nominator Information

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Life Member Nomination Form

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