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2023 Council Awards Nomination Form

Award Designation

Nominator Information

The completed nomination form must be submitted electronically no later than March 15, 2023 to be considered by the Council Awards Committee. Any letters of support should explain why the nominee merits the award and specifically relate the nominee's background to the council process.

Please follow up with Mary Ellen Fletcher if you do not receive a confirmation.

Nominated by

Date submitted

Street address

City

State

Zip

Email address

Signature

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

Chapter endorsement Yes No

Nominee

Name of nominee

Telephone

Street address

City

State

Zip

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

ACEP office held (national and chapter)

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

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