AAPA2 - Honorary Membership Nomination Form

AAPA HONORARY MEMBERSHIP NOMINATION FORM

Honorary membership is reserved for non-PAs “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 February 15.Email all supporting documents and questions to awards@aapa.org.

Nominations are reviewed by the AAPA Awards Committee. 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.

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. Please note local and national contributions.

Additional Attachments: