2025_Osteopathic Family Medicine Educator of the Year Award Application

ACOFP Lifetime Achievement Award

Submission Deadline: September 15, 2024
The Lifetime Achievement Award recognizes an outstanding individual who demonstrates career-long service to patients, to the profession of osteopathic family medicine, and to the American College of Osteopathic Family Physicians.

Award qualifications include:
- Must be an active ACOFP member in good standing.
- Must have no current restrictions on any medical licenses at the time of application.
- Must demonstrate exemplary service and leadership at the national or state level.
Award requirements include:
- Submission of one letter of support from the nominator.
- Submission of one letter of support letter from their ACOFP affiliate society. In cases where an ACOFP affiliate society is not available, the letter must come from a national leader.
Nominator Information
Nominator Name *
Phone Number*
Email*
example@example.com
Nominee Information
Nominee Name*

First NameLast Name
Suffix
Designation*
Company or Institution
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Does the nominee have any current restrictions against their medical licenses?*

YesNoRetired from Practice
If yes, please provide an explanation:
Has the nominee had any restrictions within the past two years against their medical licenses?*

YesNoRetired from Practice
If yes, please provide an explanation:
C/V File Upload*

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Letter of Support from Nominator File Upload*

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Letter of Support from ACOFP Affiliate Society*

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Additional Letter of Support (Optional) File Upload

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Professional Head Shot Photo Upload (high-resolution images only) *

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By signing below, I certify that, to the best of my knowledge, the information provided for the nominee in this application is true and accurate.
Signature*

Clear
Date*

MonthDayYear
Date
All completed submissions must be received by September 15, 2024. Applicants will be notified of the selection results via email no later than December 1, 2024.

Please contact Tina Burk at tinab@acofp.org if you have any questions.
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ACOFP Lifetime Achievement Award

Nominator Information

Nominee Information