FHM Letter of Support Request Form

To properly recognize the accomplishments of both Fellows, and Senior Fellows, in Hospital Medicine, SHM would be honored to send a letter of acknowledgment to your group leader, administrator or whomever else you would request.

Any Fellow or Senior Fellow may request to have a letter sent on their behalf by completing the request form below. Please note that only requests from current FHM's or SFHM’s will be honored and allow up to one month for processing.

Your contact information as you would like it to appear in the letter
*	First name:
*	Last name:
	Credentials:
*	Organization:
*	Title:
*	E-mail:
	SHM membership#:

Person to whom letter should be sent as it should appear in the letter
*	Salutation:
*	First name:
*	Last name:
	Credentials:
*	Organization:
*	Title:
*	Mailing address line 1:
	Mailing address line 2:
	City:
	State:
	Zip code:
	Country:
		* indicates a required field

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