Award Nomination Form

Date of Nomination: City, State Zip Code

1. Name of Phone Nominee/Credentials

Email address Home Address 4. Award Candidate is being Nominated For: City, State Zip Code Nomination Deadline for FPD: Phone January 15 Daniel D. Home Email Address Vigness Federal Political Director Award (Formerly Federal 2. Nominee’s Present Political Director of the Position, Affiliation and Year) Bus. Address:

Position/Organization Nomination Deadline for Annual Meeting Awards: Street Address March 15 Agatha Hodgins Award City, State Zip Code Helen Lamb Outstanding Educator Business Phone Award Alice Magaw Outstanding Email address Clinical Practitioner Award Ira P. Gunn Award Clinical Instructor of the Year Award 3. Name of Nominator Didactic Instructor of the Year Award Street Address Program Director of the Year Award

5. Describe what you consider to be the candidate’s most outstanding contributions to the nurse anesthesia profession and why this nominee should receive this specific award (field will enlarge as you type): Note Nomination Deadline! – FPD Award = January 15

Check List for Federal Political Director Nomination: Completed Nomination Form 1 Letters of Support from member of State Association Nominee’s Curriculum Vitae Nominee’s Photo

Note Nomination Deadline! – Annual Meeting Awards = March 15

Check List for Annual Meeting Award Nominations: Completed Nomination Form 3 Letters of Support (no more than 3 letters will be accepted Please do not include a letter from the nominator as one of the support letters.

Note: For the Faculty Awards, one of the letters of support must be from students.

Nominee’s Curriculum Vitae Nominee’s Photo

Instructions:

 Please fill out this nomination form and include all material listed above.

 All information received will be deemed confidential.

 The AANA Board of Directors will select the Awards recipients

 Members of the Board of Directors are not eligible during their terms of office.

 IMPORTANT: Nominees remain in the pool of candidates for a total of 3 years of consideration. After 3 years a new nomination package must be submitted if you wish you have a nominee reconsidered for another 3 year period.

Return Email Completed Nomination forms by deadline to: [email protected]

or mail COMPLETE nomination package to:

American Association of Nurse Anesthetists Executive Unit 222 S. Prospect Ave. Park Ridge, IL 60068

APPLICATIONS NOT COMPLYING WITH INSTRUCTIONS AND FORMAT WILL NOT BE REVIEWED