Physician Leadership Program Nomination Form

Physicians: If you are being nominated for the Physician Leadership Program by an EBAA member eye bank, please complete the form below. The deadline to submit the form is October 31.

EBAA Members: To nominate a physician to attend the Physician Leadership Program, please have the physician complete the form below and provide them with a support letter detailing your support and the reasons you think that the physician should attend the program.

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Nominee Information

Please enter the information for the physician who is being nominated for the program.

Nominee Name*

First Last Suffix

Nominee Email Address:*

Work Phone

Mobile Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Address Type:*

Work

Home

Name of Organization/Institution/Practice*

Fellowship Information

When and where did you complete your Cornea Fellowship? Who was your Fellowship Director?

Eye Bank Relationship

Sponsoring Eye Bank*

Eye Bank Executive Director Name*

First Last

Eye Bank Executive Director Email

What is your relationship to the sponsoring eye bank?

Medical Director

Associate Medical Director

Eye Bank Medical Advisory Board Member

Board Member

Receive Tissue for Surgery/Research

Consultant

Other

If “Other”, please explain.

How long have you been involved with your eye bank?*

What motivated or prompted you to become interested in eye banking or to work with your local eye bank?*

Personal Statement

Why do you want to attend the Physician Leadership Program and how do you think the Physician Leadership Program will help you in your career? In your work with the eye bank? In other areas?*

File Upload

Please use this section to upload your CV and a letter of support from the Executive Director of the sponsoring eye bank.

Please attach a current CV

Drop files here or

Accepted file types: pdf, doc, Max. file size: 25 MB.

Please attach a letter of support from the Executive Director of the sponsoring eye bank.

Drop files here or

Accepted file types: pdf, doc, Max. file size: 25 MB.

Headshot

Please upload a headshot to be used if selected for the Physician Leadership Program.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 25 MB.

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Nominee Information

Eye Bank Relationship

Personal Statement

File Upload

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