AAPA PAragon Awards Nomination Form

Thank you for taking part in the American Academy of Physician Assistants annual PAragon Awards program and for helping AAPA bring attention to the outstanding work by PAs across the country and around the world.

Please submit only one form for each person being nominated. You may nominate as many people as you wish.

If this is a nomination for the Federal Service PA of the Year Award, please speak with a representative of one of AAPA's recognized federal service constituent organizations — Naval Association of PAs, Society of Air Force PAs, Society of Army PAs, Public Health Service Academy of PAs, Veterans Affairs Physician Assistant Association, or Veterans Caucus. Nominations are made by the boards of directors of the federal service constituent organizations, and they should fill out the Federal Service PA of the Year Award Application Form.

Individuals interested in applying for the PAragon Publishing Awards must use the Publishing Awards Application Form. Do not use this form to apply for a Publishing Award.

For more information about the different PAragon Awards, please visit the Awards Page on the AAPA Web site. For more information, call 703/836-2272, ext. 3515, or send an e-mail message to awards@aapa.org.

*indicates response required

MY CONTACT INFORMATION

*My Name:

*Address:

*City/State/Zip:

*Phone:

E-mail Address:

AAPA Member ID# (if applicable):

I WOULD LIKE TO NOMINATE SOMEONE FOR THE FOLLOWING AWARD

I would like to nominate someone else for the following PAragon Award. (Please select one.)

Outstanding PA of the Year

PA Service to the Underserved Award

Humanitarian PA of the Year

Physician-PA Partnership Award

I WOULD LIKE TO NOMINATE MYSELF FOR THE FOLLOWING AWARD

I would like to nominate myself for the following PAragon Award. (Please select one.)

Outstanding PA of the Year

PA Service to the Underserved Award

Humanitarian PA of the Year

Physician-PA Partnership Award

Candidate’s Name (if not myself):

Candidate's Phone Number:

Candidate's E-mail Address:

AAPA Member ID# (if known):

*Briefly describe why the candidate (or you) should receive this PAragon Award.

In order for the judges to appropriately compare the different candidates for the PAragon Awards, they request detailed information about each candidate. Please select from the list below.

I am nominating myself for the award. Please send an electronic copy of the application form to my e-mail address above.

I will fill out the application form with the candidate's permission. Please send an electronic copy of the application form to my e-mail address above.

Please send the application form to the candidate to fill out and tell him/her I am the nominator.

Please send the application form anonymously to the candidate to fill out (without revealing that I nominated this individual).

How did you learn about the PAragon Awards program? Select one.

Thank you for participating in the AAPA PAragon Awards process.