2018 Leadership and Excellence Award Nomination Form

Award Designation
Please check one

  

 

Nominator Information

The completed nomination form and the nominee's curriculum vitae must be submitted electronically, preferably in Word format, to Mary Ellen Fletcher, CPC, CEDC, at mfletcher@acep.org no later than April 2, 2018 to be considered by the Awards Committee. Up to three letters of support for the nomination may also be submitted. Letter of support are greatly encouraged and are at the discretion of the nominator. The letters of support should explain why the nominee merits the award and specifically relate the nominee's background to the award criteria. Please also submit any letters of support in Word format.

Receipt of each nomination will be confirmed by e-mail. Please follow up with Mary Ellen Fletcher if you do not receive a confirmation.

Nominated by:    

Date Submitted:   [None] Select a Date Delete the Date

Address:    

City:  

State:  

Zip: 

Email:  

Signature: 

By typing your name and checking the following button, you are agreeing that this is your electronic signature.

                                     

Chapter Endorsement:   

Nominee

Name of Nominee:   

Telephone: 

Address:     

City:   

State:  

Zip:

Please state why this person should be honored with this award, based on criteria indicated in the Awards brochure:
 

ACEP Offices Held (National and Chapter):
 

Committees (National, Local/Name of Committee and Length of Service):
 

Other Emergency Medicine-Related Services (Title and Length of Service):
 

Other Activities of Special Merit (Civic, Institution, etc.)
 

To complete the application, a CV must be submitted electronically.You must click "Submit" to complete this portion of the application. You will then be directed to another page to submit the CV.


      

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