ANAC Awards Application

Please complete the following application in order to nominate yourself or a colleague for one of ANAC's prestigious awards.  If you have any questions, please contact ANAC's National Office at 330-670-0101.

ANAC Awards Application

Please complete the following application in order to nominate yourself or a colleague for one of ANAC's prestigious awards.  Please be sure that you have read through the Awards Description and Eligibility Documents before proceeding.  This form will not automatically save what you have entered, and if you close out of the form before submitting, you will lose all contents.  Please be prepared to submit the entire form in one session.  In order to submit your application, please complete all required fields and scroll to the very bottom of the form and click "Submit."  Your application will not be filed until you click the "Submit" button.  Deadline:  July 15th

NOMINEE'S INFORMATION

Award Category (Please select ONE): *
Nominee's Name: *
ANAC ID# (if known):
Email Address: *
Preferred Mailing Address: *
City: *
State
Zip Code:
Country: *
Employer Name: *
Work Address:
Position/Title: *
Area of Nursing Practice (Select all applicable areas): *
If Other, please describe:
Is the nominee a current member of ANAC? *

Clear Selection
Please confirm that the nominee consents to being nominated for this distinguished award: *

Clear Selection

If the nominee is selected, will the nominee attend the Awards Ceremony at this year's ANAC Annual Conference?  (This is informational only/ The nominee’s ability to attend will not have any impact on the decision of the Award Winner.)


Clear Selection

NOMINATOR'S INFORMATION

Only one Nominator is required.

If there are more than one nominators, please complete the information requested for second and third nominators.

Nominator's Name: *
Nominator's Email: *
Preferred Mailing Address: *
City: *
State
Zip Code:
Country *
Preferred Phone: *
Phone Type: *

Clear Selection
Relationship to Nominee (Select all that apply): *
If Other, please explain:
Nominator's Current Position/Title: *
Second Nominator's Name:
Email Address:
Phone Number:
Relationship to Nominee (Please select all that apply):
If Other, please explain:
Third Nominator's Name:
Email Address:
Phone Number:
Relationship to Nominee (Please select all that apply):
If Other, please explain:

Instructions:  All nominators need to download and review all sections of the FAQ for the appropriate Award Category.  The FAQ documents will provide guidance on completing the following sections for each Award Category.  All sections have a 2,000 Character limit.  The system will decline your submission if any section exceeds 2,000 characters.  Thus, we recommend you save your responses in a Word document so that you have a backup of your work.

Introductory Statement by Nominator: *
Describe the Nominee's Commitment & Contribution to HIV/AIDS Nursing *
Position Role/Description *
Collaboration *
Compassionate Caregiving *
Innovation & Creativity *
(Maximum characters: 2000)
You have characters left.
Additional Supporting Information (Not required):
Nominator #2 Statement (Only if applicable):
Nominator #3 Statement (Only if applicable):

The following questions apply only for the ANAC Researcher Recognition Award

If you are nominating someone for the ANAC Researcher Recognition Award, please upload his/her CV here.
If you are nominating someone for the Researcher Recognition Award, please upload only one letter of support here.





Fields marked with * are required.

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