Award Application Coversheet

To be filled out by all award applicants

The purpose of this form is to streamline the application process so that the Awards Committee and subcommittees can notify applicants when applications are received and when the final decision has been made. Please attach a completed copy of the coversheet to each separate application submitted and fill out the other necessary forms as instructed by the application instructions.

Name as you would like it to appear on your award:

______

Address:______

______

Phone:______

Fax:______

Email:______

Award(s) for which the applicant is applying: (Please check all that apply)

Bio-Rad Professional Achievement / Theriot
Member of the Year / Gloria F. “Mike” Gilbert
New Professional of the Year / I. Dean Spradling Graduate Research Grant
Student Forum Leadership / Member Research Grant
Publication / ESA case study
Scientific Research / ESA research paper

** If you do not receive confirmation of application receipt within 2 weeks, please contact the responsible person or persons who are in charge of that award for verification**

Please send to:

ASCLS MEMBER OF THE YEAR

CONSTITUENT SOCIETY NOMINATION FORM

To be completed by constituent society President or Regional Director

The ______

(Name of the Constituent Society)

presents, as its candidate for this year's ASCLS Member of the Year,

______

(Name of nominee)(ASCLS #)

______

(Street address)(City) (State) (Zip)

______

(Business phone, include area code)(Home phone, include area code)

______

(E-mail address)

Method of nominee selection: ______

** Please attach an essay explaining why the members of this constituent society feel the candidate merits the award. Points are awarded from the essay in the area of significant contribution to the profession.**

Signed: ______

(President/Regional Director of constituent society)

______

(Street address)(City)(State) (Zip)

______

(Business phone, include area code)(Home phone, include area code)

______

(E-mail address)

MEMBERSHIP VERIFICATION: (for office use only, do not write in this space)

APPLICANT INFORMATION

This Section To Be Completed By All Applicants

Please mark the award for which information is being submitted

__Bio-Rad Professional Achievement

__Member of the Year

__New Professional of the Year

__Student Forum Leadership Award

NAME: ______

(as you would like it to appear on the award)

ADDRESS:______

PHONE: ______

EMAIL: ______

ASCLS MEMBER #: ______

YEARS IN ASCLS: ______

EDUCATION:

College/University attended or attending: ______

Program attended or attending: ______

Highest degree obtained: ______

Dates attended: ______

Certification(s) number and year received: ______

YOUR SIGNATURE:______

SECTION I: ORGANIZATION ACTIVITIES

(ALL APPLICANTS – Member of the Year, New Professional of the Year, Student Forum Leadership, Bio-Rad Professional Achievement )

Please complete each section for which you have activities. It is recognized that you may not have activities for every area. If you need additional room please use a separate sheet of paper and identify it with the applicant name.

Name ______

1.Local, Chapter, or Branch

Office (s) held and year (s) held: (Secretary, Treasurer, Board Member, etc.)

Activities: (Specify the activity and your role)

2.Constituent Society

Office (s) held and year (s) held: (Secretary, Treasurer, Board Member, etc.)

Activities: (Specify the activity and your role)

3.Regional

Office (s) held and year (s) held: (Secretary, Treasurer, Board Member, etc.)

Activities: (Specify the activity and your role)

4.National

Office (s) held and year (s) held: (Secretary, Treasurer, Board Member, etc.)

Activities: (Specify the activity and your role)

Please indicate the following for each meeting: (D) Delegate, (A) Alternate, or

(S) Student Delegate/Representative

Meeting/Year / D/A/S / Meeting/Year / D/A/S / Meeting/Year / D/A/S
Los Angeles 2012 / Atlanta 2011 / Anaheim 2010
Chicago 2009 / Washington, DC 2008 / San Diego 2007
Chicago 2006 / Orlando 2005 / Los Angeles 2004
Philadelphia 2003 / Orlando 2002 / Chicago 2001
New Orleans 2000 / Chicago 1999 / Chicago 1998
Atlanta 1997 / Chicago 1996 / Anaheim 1995
Nashville 1994 / Washington 1993 / Boston 1992
Atlanta 1991 / Los Angeles 1990 / Washington 1989
San Antonio 1988 / Las Vegas 1987 / New Orleans 1986
Orlando 1985 / San Antonio 1984 / Los Angeles 1983
Houston 1982 / Miami 1981 / St. Louis 1980
Las Vegas 1979 / Kansas City 1978 / Atlanta 1977
Chicago 1976 / San Francisco 1975 / New Orleans 1974
Boston 1973 / Minneapolis 1972 / Las Vegas 1971

SECTION II: To be completed by

MEMBER OF THE YEAR NOMINEES ONLY

(If this does not apply, please continue to the appropriate section)

NAME______

1.Professional Employment and Experience

Current Position and Title: ______

Current Employer (including address): ______

______

______

Previous Employment (last five years)

EmployerPositionDates

Teaching Experience (last five years; indicate faculty appointment where appropriate)

InstitutionSubjectDates

2.Professional, Honor, and Other Societies (Membership and services to professional societies related to clinical laboratory sciences; e.g., Alpha Mu Tau)

Membership in and service to:______

Office held (indicate local, state, regional, or national):

OrganizationOfficeNumber of TermsYears Held

Activities (Indicate if (L) local, (S) state, (R) region, or (N) national):

OrganizationChair/MemberNumber of TermsYears

3.ASCLS Awards(Please indicate award and year received for all awards)

  • National Awards

(ASCLS BOD, Mendelson, Gilbert, Kendal or Bio-Rad, Theriot, Scientific Research, Kleiner, CLS Distinguished Author, Omicron Sigma, Member of the Year, Student Leadership)

  • Region/State/Local Awards (Also indicate award level (R- region, S- state, or L- local))

(Member of the Year, Keys to the Future, Omicron Sigma)

  • Honors

(Including Pyramid Club and others)

  • Other professional awards from organizations related to clinical laboratory science

4.Contributions to the Profession

This section should include all activities and/or special products not outlined previously on this form, as they relate to the promotion of clinical laboratory sciences in the community. Included are contributions such as time dedicated to NCA and NAACLS activities, government and licensure activities, Student Forum involvement, health fairs, career day, NMLPW activities and others. Include a brief description of the activity and your involvement in it. Be concise, specific and accurate in your presentation. Please include level and year for each activity listed.

Level Activity Year(s)

National, Regional,

State, Local

______