ANCOR Foundation 2021 Legacy Leaders Circle Nomination FormImage Banner

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ANCOR Foundation 2021 Legacy Leaders Circle Nomination Form

The ANCOR Foundation Legacy Leaders Circle recognizes the accomplishments of long-term ANCOR members who made significant contributions to ANCOR during his/her tenure as a member. (Long-term is defined as minimum of 7 years.)

Nominations may be made by both ANCOR member and non-member organizations.

Please submit the completed nomination by 11:59pm (Eastern) on Wednesday, March 31, 2021.

Nominator Information
Numbers only. No parentheses or dashes.
Numbers only. No parentheses or dashes.
Nominee Information
Numbers only. No parentheses or dashes.
Numbers only. No parentheses or dashes.
For publicity purposes, submit a digital photograph (headshot) of the nominee. GIF or JPG only. Max file size 5 MB. If you are experiencing issues attaching a photograph to this form, then send it via e-mail to mcampos@ancor.org.
Files must be less than 5 MB.
Allowed file types: gif jpg.
Period of ANCOR Membership
Indicate in which area(s) of distinction this individual would qualify for the ANCOR Legacy Leaders Circle (check all that apply)
Describe the individual’s accomplishments in the areas checked above in terms of advancing ANCOR (250 maximum word length)
ANCOR wishes to continue learning from its distinguished leaders
Nomination Process

Nominations are due by 11:59pm (Eastern) on Wednesday, March 31, 2021. The Legacy Leaders Circle Committee submits its recommendations for Legacy Leader Circle Award recipients to the ANCOR Foundation Board for consideration and approval. The nominator will be contacted regarding the final decisions by Friday, April 9, 2021. If your nominee is selected, the nominator will receive instructions to prepare for the awards presentation as well as conference details to arrange travel for the award recipient. The awards presentation will be held on June 16, 2021 at the 2021 ANCOR Annual Conference.

Terms of Nomination

By completing this nomination, I certify that, to the best of my knowledge, this individual has not been convicted of Medicaid/Medicare fraud or any other criminal activity. I agree to ensure the nominee's travel expenses will be covered to enable him/her to receive the award at the ANCOR Annual Conference.