Application form

Thank you for accessing the nomination form. Please ensure to complete all required fields to successfully submit your entry. We encourage you to prepare your answers on a separate document first as you will be unable to save your progress and submit it later. You may enter as many award categories as you like, tailoring each nomination to the criteria of 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 2022 and June 2023.

    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. Min 100 words.

    words. Please limit to 400 words or less Without Space

    Question 2: How has Pen CS software, such as CAT or Topbar, supported the nominee to achieve this outcome? Min 100 words.

    words. Please limit to 400 words or less Without Space

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

    words. Please limit to 400 words or less Without Space