Legacy Leaders Circle Awards Nomination

Legacy Leaders Circle Award Nomination Process

Nominations are due by Tuesday, January 24, 2023.
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 February 11, 2023.
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 April 26, 2023, at the ANCOR Annual Conference.

Please complete the form below to submit your nomination for a 2023 Legacy Leader Award. Submissions are due by Tuesday, January 24, 2023.

Legacy Leader Circle Award Submission

Nominator Information

Name(Required)

First Last

Pronouns

Organization(Required)

Job Title(Required)

Email(Required)

Phone (Work)(Required)

Numbers only. No parentheses or dashes.

Phone (Mobile)

Numbers only. No parentheses or dashes.

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Relationship to Nominee(Required)

Nominator Criteria(Required)

I certify that I have reviewed and accept the Nominator Criteria as listed below.

Nominator Criteria: Nominations may be made by both member and non-member organizations of ANCOR. We welcome self-nominations, and we also encourage nominations from organizations’ boards or other community members.

Current employees of an organization may make a nomination, but that nomination must be approved by the Chief Executive Officer. If the nomination is the Chief Executive Officer, the nomination must be endorsed by the organization’s Board of Directors.

Nominee Information

Name(Required)

First Last

Pronouns

Organization(Required)

Job Title(Required)

Email(Required)

Phone (Work)(Required)

Numbers only. No parentheses or dashes.

Phone (Mobile)

Numbers only. No parentheses or dashes.

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Posthumous Nominee

Yes

Check here if distinction is being submitted posthumously.

Nominee Photo

Accepted file types: jpg, png, Max. file size: 5 MB.

For publicity purposes, submit a digital photograph (headshot) of the nominee. PNG or JPG only. Max file size 5 MB. If you are experiencing issues attaching a photograph to this form, then send it via email to [email protected]

Duration of ANCOR Membership

Estimated duration of ANCOR Membership. If available, please include membership start year and end year.

About the Nominee(Required)

Identify and describe at minimum three ways the nominee’s time and/or talents have resulted in a positive legacy for ANCOR and its members. We encourage you to consider the ripple effects the nominee’s actions have had on the individuals, the organizations, and the community at-large. (500 maximum word length)

Nominee Engagement(Required)

The nominee DOES know that they are being nominated.

The nominee DOES NOT know that they are being nominated.

Nominee Engagement

If the nominee knows of the nomination, indicate how the identified nominee wishes to continue their ANCOR engagement.

Submission

Terms of Nomination(Required)

I agree to the 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 them to receive the award at the ANCOR Annual Conference. 

Electronic Signature(Required)

First Name Last Name

Date(Required)

Electronic Signature(Required)

I agree to the Electronic Signature policy.

I understand that clicking “Submit”, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

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Legacy Leaders Circle Awards Nomination

Legacy Leaders Circle Award Nomination Process

Legacy Leader Circle Award Submission

Nominator Information

Nominee Information

Submission