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 ANAC's Excellence in Global HIV Nursing Award. Please be sure that you have read through the Awards Description before proceeding. Please be prepared to submit the entire form in one session. 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. We recommend drafting your responses in a Word document and copying them in to the form. 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 is March 31, 2019.

NOMINEE'S INFORMATION

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 in Portland November 7-9th  (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 Award.  The FAQ document will provide guidance on completing the following sections for each.  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 *
Innovation and Creativity *
(Maximum characters: 2000)
You have characters left.
Compassionate Caregiving *
Collaboration *
(Maximum characters: 2000)
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Impact on local, national or international policies
(Maximum characters: 2000)
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Additional Supporting Information (Not required):
Nominator #2 Statement (Only if applicable):
Nominator #3 Statement (Only if applicable):



Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

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