Nomination Form

"Today, the need for leaders is too great to leave their emergence to chance."

The Future of Public Health,Institute of Medicine

Nominee's Full Name and Degree(s):
Nominee's Title and Organizational Affiliation:
Nominee's Address:
Nominee's Telephone (business/home):
Nominee's Email:
Positions (titles and dates) held during the performance of work for which nomination is suggested:

In 300 words or less, describe in detail the current creative work, distinguished achievements, or distinguished service which make this nominee worthy of the award, bearing in mind the award description. Be sure to speak to at least one of the Ten Essential Health Services related to the nominee’s leadership and describe the nominee’s impact on challenging the process, inspiring a shared vision, enabling others to act, modeling the way and encouraging the heart. How did the nominee demonstrate creative leadership and to what degree did the nominee influence others? The committee may request additional information in order to make a choice:

Nominator's Name:
Nominator's Address:
Nominator's Telephone (business/home):
Nominator's Email:
Date

PLEASE NOTE: Nominations must be received by March 31, 2005. A separate form must be submitted for each nomination. Nominations should be sent via e-mail, fax (518/402-0305) or mailed to the Award Committee, Northeast Regional Public Health Association, School of Public Health, One University Place, Rensselaer, New York 12144-3456. Relevant material should have the applicant’s name on every page. Nominations received after March 31, 2005 cannot be guaranteed consideration for the award. If faxing, be sure that the nominator’s name and phone number appears on each page.

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