Nominee's Name *

First Name

Last Name

Nominee's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Nominee's Phone Number *

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Which professional designation(s) does the nominee hold? *

Choose as many as you like.

ATC

MD

PA

PT

PTA

OT

OTA

EMT

RN

NP

Other

Has the nominee been a certified member living or working in Tennessee for a minimum of 15 years? *

Yes

No

I don't know

Has the nominee given a minimum of 20 years of service to the profession of athletic training? *

Yes

No

I don't know

Is the nominee being recommended by a certified member of the Tennessee Athletic Trainers' Society?

Yes

No

Has the nominee solicited nomination or tried to influence the selection process?

Yes

No

I don't know

Submitter's Name *

First Name

Last Name

Submitter's Phone Number *

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