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Award applied for: POGO Valued Contribution Award POGO Companion Award Friends of POGO Award Each nomination package must include:


POGO RECOGNITION AWARDS – NOMINATION FORM Full Name of Nominee : Professional Title : Telephone Number: E-mail address: Childhood cancer organization(s)/institution(s) with which nominee’s work is affiliated: Length of time in which the overall contribution has been made: Nominated by: Professional Title : Telephone Number: E-mail address: Signature: Length of time you have known the nominee: Relationship to Nominee (e.g. patient, colleague, etc.): Award applied for: POGO Valued Contribution Award POGO Companion Award Friends of POGO Award Each nomination package must include:  Completed and signed nomination form  Two Letters of support (one to be provided by the nominator, PLUS one other), each clearly stating the award applied for AND specifically addressing the qualifications of the candidate, matched to the criteria of the award nominated for (please refer to award descriptions included in the “POGO Recognition Awards Program Information ” document provided )  Current curriculum vitae of nominee Deadline: Nomination packages must be received not later than 12:00 noon on Wednesday , September 11 , 20 13 Mail, fax or email nomination package to: Clara Jordan, Conference & Educational Events Coordinator Pediatric Oncology Group of Ontario 480 University Avenue, Suite 1014 Toronto, Ontario M5G 1V2 Tel: 416 -592 -1232 x23 7 Fax: 416 -592 -1304 Email: cjordan @pogo. ca Any personal information collected will be used exclusively for administering the POGO Recognition Awards

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