CATHY SAMUELSON AAC ADVOCACY AWARD

CATHY SAMUELSON AAC ADVOCACY AWARD

2026 APPLICATION FORM
Part A - Nominee
Name of Nominee

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Part B - Nominator
Name of Nominator

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Part C

Please explain why the nominee should be considered for the Award and how he/she meets Award’s criteria. Point form is accepted.
Attach any documents or files to this application here:

Browse Files

Cancelof
Should be Empty: