Awards Nomination Form

CPCNA Awards Nomination Form

To nominate a nurse for either the CPCNA Leadership Award or the CPCNA Lifetime Achievement Award:

Seek the nominee’s permission to nominate him or her (Self-nominations are ineligible).
- The nominee must give permission for the CPCNA to use his or her photo and the reference letters for publicity purposes.
- The nominee must sign the nomination form (or nominator checks box confirming consent obtained in online form).
Procure two letters of support.
- Letters can be from a fellow nurse, a member of the CPCNA, another profession or a member of the public.
- Each letter should be approximately 500 words.
- Please provide specific examples of how the nominee has made significant contributions to palliative care nursing and the CPCNA.
Complete the online nomination form.
Click 'Submit"
Email the following documents to cpcnamembers@gmail.com:
- One copy of the nominee’s current CV.
- Two Letters of Support
- An electronic photo of the nominee which may be used for publicity purposes.

CPCNA Awards Nomination Form

A. Nominee Information

First Name

Last Name

Position

Employer

Credentials (i.e. education, certifications)

Mailing address

Primary Phone

Years with CHPCNG and CPCNA combined

Please share details of any roles the nominee has had with CHPCNG or CPCNA:

I confirm that the nominee is aware of and consents to being nominated for this award.

B. Nominator Information

First Name

Last Name

Relationship to nominee

Mailing address

Primary Phone

Second Nominator Information (if applicable)

First Name

Last Name

Relationship to nominee

Mailing address

Primary Phone

C. Email supporting documents

By clicking this box, you confirm that you understand that you must email the nominee's CV, two Letters of Support and a photo to cpcnamembers@gmail.com to complete the application. Applications will not be reviewed until all documentation is received.

By submitting this form as a nominator, your signature is an endorsement of the nominee and you confirm there is no evidence to support why this person should not be considered for an award. Submitting or confirming nomination via personal email / online is deemed to be an electronic signature.

Thank you for submitting this Award Nomination!