Richard Neubauer Advocate Award Nomination Form

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Please submit this form by March 25th in order for it to be considered for the upcoming Leadership Day. For questions, please contact Shuan Tomlinson at 202-261-4547 or email stomlinson@acponline.org.

Submitted by:

Nominee Name

ACP Chapter

Please provide, in as much detail as possible, the following information about the nominee:

What contributions has this individual made to ACP’s federal advocacy activities? Please be as specific as you can.

Has this individual been involved in any state-level advocacy? If so, what?

Why do you think this individual is deserving of this award?

Other Comments: