Hepatitis Elimination Champion Nomination

Hepatitis Elimination Champion Nomination

Nominee information

Contact information for individual being nominated for Elimination Champion award

Name*

Organization*

Address

Email*

Phone number

Contact information of individual submitting this form

Name*

Email*

Please describe nominee’s efforts in advancing hepatitis elimination (500 word limit)*

Primary country/region of nominee's work*

Please provide a quote about nominee's efforts to be used to publicize the award (250 word limit)

Skip this question if self-nominating

Please provide links to any media or other online descriptions of the nominee's efforts

If no website or media available for nomination, please provide a second name/email who will support this nomination.

Is there anything else you would like to add?

Upload nominee's CV and photo, if available

Please upload any other supporting documents here as well

Drag and drop files here or

Send me a copy of my responses