2026 Award Nomination Form
Nominee/Applicant Contact Information
Nominator Name (Must be a current ACOEP member)
*
First Name
Last Name
Degree
Nominator Email
*
example@example.com
Candidate Name:
*
First Name
Last Name
Candidate Email:
*
example@example.com
Go to our
website
to see descriptions and criteria for each of the awards.
For which award is the candidate being nominated?
Bruce D. Horton, D.O., FACOEP, Lifetime Achievement Award
Robert D. Aranosian, D.O., FACOEP – Excellence in EMS Award
Benjamin A. Field, D.O., FACOEP – Mentor of the Year Award
Willoughby Award
Honorary Membership Award
Honorary Fellowship Award
Practice Innovation Award
Excellence in Education Award
Candidate CV, Photo, and Letter Uploads
Attach the candidate's CV
*
Browse Files
Drag and drop files here
Choose a file
Only PDF, DOC, DOCX files are supported.
Cancel
of
Attach a letter explaining the accomplishments of this candidate and why they deserve to be recognized.
*
Browse Files
Drag and drop files here
Choose a file
Only PDF, DOC, DOCX files are supported.
Cancel
of
Please Attach a clear headshot (passport sized preferable) that the candidate would like printed in a program or press release.
*
Browse Files
Drag and drop files here
Choose a file
Only PDF, jpg, jpeg, png, and gif files are supported.
Cancel
of
By signing below I certify that the above facts are true and correct to the best of my knowledge and belief.
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: