Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. eligibility sanctions, please Person completing this formFirstLastEmail address (person completing this form)Are you completing this form to be considered yourself, or to recommend someone for consideration by the directorate for FBILM by distinction status?I wish to be considered (self-nomination)I wish to recommend someone (nominate another person)Nominee nameFirstLastCountry of residenceFull postal addressProfessional registration number(s) (if applicable)Link to professional profile/biographyHas the nominee previously applied or been nominated for FBILM by distinction status?YesNoUnsureIf yes, please provide the year and outcome, if known.Nominee email address (if known)Nominee role / titleOrganisation / institutionIs the nominee eligible to be considered for FBILM by distinction status?YesNoNot sureIf yes or not sure, briefly explain the basis of eligibility (or any relevant eligibility screening information)Which of the following best describe the nominee’s contribution? Select all that apply.Leadership in lifestyle medicineClinical innovationAcademic or research achievementEducation and trainingService developmentPublic engagement or advocacyPolicy influenceInternational contributionMentorship and workforce developmentOtherPlease explain why the nominee should be considered for FBILM by distinction status. Please explain why the nominee should be considered for FBILM by distinction status. Focus on the nominee’s exceptional contribution, the difference they have made, who benefited, and why their impact is distinctive beyond routine expectations of their role.Evidence of distinction (e.g., outcomes, publications, service impact, awards, leadership roles, policy influence, testimonials). Supporting documents may also be emailed to contact@bilm.org.ukI confirm that the information provided in this form is true and accurate to the best of my knowledge.YesNoI confirm that the nominee is aware of this submission, where required.YesNoNot applicableI confirm that I have permission to share the personal data included in this form.YesNoPlease declare any actual, potential, or perceived conflicts of interest relevant to this nominationIs there anything the directorate should be aware of regarding professional conduct, investigations, sanctions, or reputational issues relevant to the nomination?YesNoIf yes, please provide details regarding professional conduct, investigations, sanctions, or reputational issues relevant to the nominationSubmit
