Application Form - National Emergency Medicine Faculty Teaching Award

Nominee Name

E-mail Address

Institution

City and State

Years in Academics

Academic Rank

Yes

No

Nominator Name

Title

Email Address

Institution

City and State

Phone Number

Name of individual completing the application (if different from the nominator)

Email address

Yes

No

Yes

No

Endorsement by Departmental or Organizational Leadership

Endorsement by Learners

Documentation of Teaching Awards

Documentation of Educational Efforts

Documentation of ACEP Educational Programs

Documentation of Major Innovative Educational Programs

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