National Association of Community Health Centers, Inc.

2012 NACHC Community Health Care Awards of Excellence

Principal Nomination Form
(to be completed by the PRINCIPAL NOMINATOR only)

NOMINATION DEADLINE: Friday, May 4, 2012

1. Select award for which you are submitting a nomination:

2. NOMINEE Information

Name:
Title:
Health Center/PCA Affiliation:
Street Address:
City:
State:
Zip Code:
Phone (area code required):
Email:

3. Select Membership Status:

NOTE: If not a Current NACHC Individual Member, please refer to the Member Center or contact the NACHC Membership Department at 301.347.0400.

Individual Membership is not required for nominees for the Innovative Research Award or public officials nominated for the Aaron L. Brown Award.

4. NACHC Individual Member Number (6 digits):

5. NOMINATOR Information

Name:
Title:
Health Center/PCA Affiliation:
Street Address:
City:
State:
Zip Code:
Phone (area code required):
Email:

6. Select Membership Status:

NOTE: If not a Current NACHC Individual Member, please refer to the Member Center or contact the NACHC Membership Department at 301.347.0400.

7. NACHC Individual Member Number (6 digits):

8. Nomination Statement:
Please describe why you think the nominee should receive the selected award and how he or she meets the specific award criteria to merit recognition. Responses are limited to 300 words.

Supporting Nominators

Please submit the names and email addresses of the two individuals you have identified as Supporting Nominators for your nominee. A password will be sent by email to these individuals so they may access the Supporting Nomination Forms for your specific nominee. A nomination will not be considered complete until all forms have been submitted by the May 4th deadline.

9. Name and Email Address of Supporting Nominator One

Name
Email Address

10. Name and Email Address of Supporting Nominator Two

Name
Email Address

A confirmation email will be sent to you upon submission of each required form for your nomination.

NOMINATION DEADLINE: Friday, May 4, 2012