Application

To submit your application form please complete all fields below.
You must complete this form it in one viewing, as you are unable to save and submit later.

We encourage you to prepare your answers in a separate document first.

You may enter as many award categories as you like, however each nomination must be tailored to the award category.

    Are you nominating yourself?:

    Current nominator contact details

    Contact name:

    Name of organisation:

    Phone:

    Email:

    Current nominee contact details:

    Contact name:

    Name of organisation:

    Phone:

    Email:

    Images received will be used for promotion of the Pen CS Awards by Pen CS.

    Please upload the nominee(s) image:

    Files cannot be larger than 5MB each.
    Examples include photos of the nominee(s) practice team, their team at work or a photo of their practice.

    Please upload the nominee(s) organisation's logo:

    Files cannot be larger than 5MB each.

    AWARD CATEGORY

    Please follow the maximum word limit for each nomination question; dot point responses are encouraged. The achievements described in the nomination must have been completed within Australia and have taken place between July 2021 and June 2022.

    For all Pen CS award category nominations, the same questions will apply. Please answer the following questions.

    Question 1: How has the nominee positively impacted health outcomes within their local Australian community? Be sure to identify how a problem was resolved, any outcomes that resulted from this achievement and support your response with quantitative evidence and/or research. Max 300 words.

    words. Please limit to 300 words or less Without Space.

    Question 2: How has Pen CS software, such as CAT or Topbar, supported the nominee to achieve this outcome? Max 200 words.

    words. Please limit to 200 words or less Without Space.

    Question 3: How has the nominee demonstrated their value and contribution to the chosen award category? Max 100 words.

    words. Please limit to 100 words or less Without Space.