Life Membership Nomination Form

Nominee Details

Nominee Name(Required)

First Last

Nominee Email Address(Required)

Nominee ACCCN Member Number (if known)

Nomination Details

Brief description of the rationale for Nomination (2-3 sentences)(Required)

Criteria 1: Notable contributions to the College(Required)

Provide a detailed description of the nominee’s contributions to the College. Please include details of the duration of College membership and participation in and contribution to College activities, events, committees, or boards.

Criteria 2: Notable contributions to critical care nursing(Required)

Provide a detailed description of the nominee’s contributions to critical care nursing. Begin by indicating the main area(s) of contribution (Research, Education, Leadership or Patient Care/Clinical Practice), and then provide evidence of the nominee’s notable contribution(s).

Supporting Evidence

Drop files here or

Max. file size: 128 MB.

Upload any relevant documentation related to the nominees contributions to the ACCCN and critical care nursing.

Nominator Details

Nominator Name(Required)

First Last

Nominator Email Address(Required)

Nominator Phone Number(Required)

Declaration(Required)

I confirm the information provided is accurate to the best of my knowledge.

I understand the nomination will be reviewed by the relevant State Committee President and the ACCCN National Board.

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Life Membership Nomination Form

Nominee Details

Nomination Details

Nominator Details

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