IMS Ambassador Nomination Form

Do you know a colleague who would be a great ambassador for the Iowa Medical Society? Or are you interested in getting more involved? Submit a nomination for the IMS Ambassador Program today!

Fields marked with an * are required.

Nominee Name *

Nominee email *

Nominee phone (cell preferred) *

Nominator name (if different)

Nominator email (if different)

Nominator phone (if different)

What is the name of the nominee's clinic/practice? *

Why are you nominating this person to be an IMS ambassador? *

*If self-nominating, please tell us why you think you would be a good ambassador to IMS.

IMS Ambassador Nomination Form

Please verify that you have checked the “I'm not a robot” checkbox.

Iowa Medical Society