Honorary Membership Nomination Form

AAPA HONORARY MEMBERSHIP NOMINATION FORM

Honorary membership is reserved for non-physician assistants “who have rendered distinguished service in the physician assistant profession. Honorary members shall have all the rights and privileges of the Academy with the exception of voting, holding office, and/or chairing committees.” (AAPA Bylaws, Article III, Sect. 9)

Nominations are due at AAPA’s national office by January 15. Either fax this form to 571-319-4402 or mail it to Awards, c/o AAPA, 2318 Mill Road, Suite 1300, Alexandria, VA 22314. Questions should be addressed to awards@aapa.org.

Nominations are reviewed by the AAPA Awards Work Group. The judges evaluate each nomination on its merits. If accepted for honorary membership, AAPA staff notifies your nominee and you that the honor will be conferred.

AAPA underwrites the honoree’s costs associated with the conferring of the honorary membership at the PAragon Awards ceremony at the Annual Physician Assistant Conference (round trip transportation, one night's lodging, two days per diem).

I nominate the following individual for Honorary Membership in the American Academy of Physician Assistants:

Nominee's Name (First, Middle Initial, Last):

Title:

Work Address:

City:

State:

Zip Code:

Work Phone:

Home Phone:

E-mail Address:

Your Name:

Street Address:

City:

State:

Zip Code:

Work Phone:

Home Phone:

E-mail Address:

Does you nominee know that you are nominating him or her?

Yes

No

How long has the nominee been associated with the PA profession?

In what capacity?

Describe your nominees outstanding personal qualities

Please describe the nominee’s distinguished service and contributions to the PA profession. List up to 10 contributions, using short, clear statements. Address how your nominee improved the ability of PAs to deliver quality, cost-effective health care; how he or she has enhanced the public image of PAs; and his or her persistence in the face of encountered opposition. This section must be completed. A curriculum vitae may be attached as a supplement, but does not replace answering this question.

Additional Attachments:

* Indicates Response Required