Awards nomination form

Once a year, doctors working in rural and remote Australia are singled out and celebrated for their skills, professionalism, and dedication to their communities.

Please submit the following online form to nominate someone who deserves recognition in one or more of the following categories. If you prefer to print the forms view download options here.

Nominations close on Monday 2 July, 2018.

Download and print award nomination forms

If you wish to download and/or print the nomination form applications should be marked private and confidential and sent to: The Awards Committee, Australian College of Rural and Remote Medicine, GPO Box 2507, Brisbane QLD 4001; or faxed to 07 3105 8299 or emailed to:

Online award nomination


Nominee for Award:

Sponsor 1 details:

Sponsor declaration

Sponsor 2 details:

Sponsor declaration

Details of application:

Please provide any information relevant to the award criteria.  This could  include the nature of service given; how this service has contributed to the College; furthered recognition of the discipline of rural and remote medicine; or service to rural and remote communities.

Additional attachments