ArkSHA Poster Ambassador Nomination Form

Additional documentation for nominations can be attached before hitting send or can be mailed to PO Box 24103, Little Rock, AR 72221 or emailed to arksha@arksha.org Documents should be typed and single-spaced. Total pages are not to exceed 5 numbered, single-spaced, typed pages including nomination and summary forms and letter(s) of support. Pages beyond this number will be removed before distribution to the Honors and Awards Committee. Additional information will be requested if necessary.

Nominee Information

Name of Nominee

Address

City/State/Zip

Nominee Email

Phone

Person Making Nomination

Your Name

Professional title/Affiliation

Your Email

Phone Number

Please provide a brief statement of nomination – stating why this individual is nominated in three sentences or less.

Photo of Nominee

Supplemental Material

Supplemental Material should include Narrative text that provides the rationale for why this individual is being nominated. Consider the following points for the narrative text: a. Description of the significance of the achievement b. Explanation of how the nominee's actions have advanced knowledge in the area of clinical practical or research. c. Explanation of the nominee's role in the achievement