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Select myself for a self-nomination or someone else if nominating another.
Nominators name | Email address | Work address
Preferred phone number. Can be a mobile.
Hospital, university, company etc. We do not need the address
Please leave blank if you can't find it
Describe how you, or the person you are nominating, have benefitted patients. Please describe the project clearly in lay terms, in addition to any scientific/technical content:
Please ensure that this section is completed in detail as it, together with the submitted evidence below, will be used to determine winning applications. Refer to the award guidance notes for further information
Refer to the award guidance notes for further information.