Arthritis Alliance of Canada Annual Research Awards Program
Recognizing contributions in Arthritis Research
Name of Applicant:
Address:
Telephone:
Email:
Indicate type of representation:
¨ Member or Board Member of a patient organization______
¨ Consumer representative for a non-patient organization______
¨ Individual advocate (unassociated with an organization) ______
Please support your application with the following items:
¨ A Letter of Support from the Nominator
¨ Example of the applicant’s active participation and contributions in arthritis research (activities, outcomes, publications, reports, conference presentations, speaker engagements, etc.) (2 pages maximum)
Name of a Nominator (incl. Position either as a volunteer or employee of an organization):
Address:
Telephone:
Email:
Nominator (Stakeholder) signature: Applicant’s Consent signature:
______
1 / Arthritis Alliance of Canada Annual Research Awards Program: Application Form_PatientJuly 2016