Awards of Distinction Nomination Form

Please use the form below for your nominations. Note complete all sections of the on-line form.

Nominated for Excellences in:



- Select One - Award for Excellence in Research Award for Excellence in Clinical Practice Award for Excellence in Education Award for Excellence in Leadership Exceptional Ethical Behavior and Professional Committment Award


I. Personal Data

Nominee's Name:
Credentials:
Mailing Address:
City, State and Zip Code:
E-mail:
Work Phone:
Home Phone:



II. Employment Experience


Present Position / Title:
Employer:
Significant Former Positions Pertinent to this Award:

III. Educational Degrees:


Nursing Degree(s):
Other Pertinent Degree(s):

IV. Membership in Professional Organizations (Pertinent to this Award):


Professional Organizations

V. Publications, Honors, and Awards received (Pertinent to this Award):


Publications, Honors, and Awards

Letter of Support (one letter from a colleague other than the nominator). Email letter to Mary Doyle at Mdoyle6@cox.net with the subject of Awards of Distinction Nomination or copy and paste your letter in the text box below.


Letter of support

Nomination completed by:


Name:
Title:
Mailing Address:
City, State and Zip Code:
E-mail:
Work Phone:
Home / Cell Phone:

Nominator and Nominee must be active (dues paid) members of Beta Mu Chapter.


Nominations are due by February 14, 2010. Please direct any questions on this form to Mary Doyle, PhD, RN, Chair Awards Committee, Beta Mu Chapter, at her email address Mdoyle6@cox.net.