Submitted By  _____________________________________________________________    

Telephone Number  __________________________________________

APPLICATION (to be submitted by county representative)
          
 Email Address  ______________________________________________

Name of Prospective Recipient  _______________________________________________

Professional Medical Organization/s  ____________________________

Home Address  ______________________________________________

                             ______________________________________________

Telephone Number  __________________________________________

Email Address  ______________________________________________

Name of the Health Issue  ____________________________________________________

Who benefited from the project or program?  _________________________
 
_________________________________________________________________

Dates of the Project  _______________________________________________

One time event or continuing?  If continuing, when was the start date?

_________________________________________________________________

 

On a separate sheet of paper, explain why this applicant should receive this award.

Thank you,

 

CALIFORNIA MEDICAL ASSOCIATION ALLIANCE

 

MAIL OR EMAIL INFORMATION TO:
CMA ALLIANCE OFFICE
1201 J Street, Suite 300,
Sacramento, CA 95814

(916) 551-2028
Fax (916) 551-2029
E-Mail: alliance@cmanet.org