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About PHIMA - Distinguished Member Award

Nomination for PHIMA Distinguished Member Award

Applications must be submitted no later than January 31, 2009.

Consideration Requirements:

  1. At least one (1) letter of recommendation from the sponsoring individual or local chapter completing this application
     

  2. Two (2) additional references
     

  3. Full completion of the below application

NOTE: It is necessary to complete this nomination form in detail because the information furnished on this form is the only information available to the Executive Board.  The group or individual nominating this candidate may choose to provide all the information requested without informing the Nominee that they are proposing his/her name.  This is satisfactory, provided all data necessary to adequately describe the Nominee's achievements for evaluation by the Executive Board are available. 

* required information

About the Submitter  
Nomination Submitted By Individual  Local Chapter
*Name of Individual or Local Chapter  
   
About the Nominee  
*Nominee’s Name  
Title
Business Address
City
State and Zip
Zip Code
Telephone
Email
   
Employment  
Years in Field  
Present Employment Status Not Employed  Employed

List name and address of employment including length of employment and name and title of employer:

Previous position(s) or title(s):

Association Activities

Identify the association by name and list most recent activity first, including dates in each category:

Regional Level:

State Level:

National Level:

Contributions to the Profession

Published articles, books, etc.:

Teaching:

Other contributions to the profession:

The information regarding the Nominee for the PHIMA Distinguished Member Award is true and accurate to the best of my/our information.