2025_Excellence in Advocacy Award Application

ACOFP Excellence in Advocacy Award

Submission Deadline: September 15, 2024
The Excellence in Advocacy Award recognizes family physicians who have significantly contributed their time and talents to national health care policy issues at the local, state and/or federal levels on behalf of the profession and their patients.

Award qualifications include:
- Must be an active ACOFP member in good standing.
- Must be currently certified in family medicine by the American Osteopathic Association (AOA) or the American Board of Medical Specialists (ABMS).
- Must have no current restrictions on any medical licenses at the time of application.
Award requirements include:
- Submission of one letter of support from the nominator.
- Submission of one letter from the nominee's ACOFP's affiliate society. In cases where an ACOFP affiliate society is not available, the letter must come from a national leadership organization that advocates for osteopathic family medicine.
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
Is the nominee currently certified in family medicine by the AOA or ABMS?*

YesNo
List of current active state medical licenses of nominee*
Does the nominee have any current restrictions against their medical licenses?*

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

YesNo
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 File Upload*

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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 Excellence in Advocacy Award

Nominator Information

Nominee Information