Nomination Form
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1COPIC Humanitarian Award in
Honor of Harold E. Williamson
Colorado Nomination Form
The COPIC Humanitarian Award in Honor of Harold E. Williamson is presented each year to honor a Colorado
physician for volunteer medical services and contributions to the community. We specifically look to recognize
those individuals who unassumingly volunteer outside the spectrum of their day-to-day lives.
SUBMITTED BY
NOMINEE INFORMATION (please print clearly)
Your Name: _________________________________
Name: _____________________________________
Organization: _______________________________
Address: ____________________________________
Title: _______________________________________
City, State, Zip: _______________________________
Your Address: _______________________________
Phone: _____________________________________
City, State, Zip: _______________________________
Email: ______________________________________
Phone: _____________________________________
Specialty: ___________________________________
Email: ______________________________________
Years in practice in Colorado: __________________
If your nominee is not selected, may we let him/her
know of your nomination? Yes___
No___
NOMINATION DESCRIPTION
To help ensure that all candidates can be given equal consideration, we strongly recommend that you answer
the following questions as they relate to the nominee’s contributions to Colorado’s health care community.
Please print legibly or type on no more than 2 pages. A cover letter will not be considered and no other
attachments will be accepted. You will strengthen your nomination by following these instructions.
1. List and describe nominee’s specific volunteer activities (where, what, when, how often, etc.)
2. How do the nominee’s volunteer activities specifically impact his/her community?
3. Why do you feel this individual deserves to be recognized?
SUBMISSION OF NOMINATION FORM
Attach this form to your nomination description and mail to:
COPIC Medical Foundation
Attn: COPIC Humanitarian Award
7351 E. Lowry Blvd., Ste. 400
Denver, CO 80230
We may contact you for additional information if necessary. You will receive confirmation by mail once your
nomination form has been received. You will be informed either way if your nominee is selected. Nomination
forms must be postmarked by August 31st.
Questions? Contact Lindsey Sidener at (800) 421-1834 ext. 6071 or
Page 1 of 1
April 2016
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