Hall of Fame: Leaders and Legends of the Blindness Field

Hall of Fame Nomination Form 2013

Please complete form as fully as possible. Additional information may be contained in letters of support.

Nominator's Name:

Address:

Phone Number:
Email address:

Name of Nominee:

If appropriate:

Address:

Phone Number:
Email:

Career Years of Service: YYYY-YYYY:

Positions Held and Locations of Service:

Nominee's Primary Field of Service (education, rehabilitation, medical, etc):

Detailed information regarding significant contribution(s):

Honors and Awards:

Publications and/or Media Productions:

Memberships and offices held in professional organizations:

How has the nominee had an impact on your life?

Date:

Information provided is confidential.
Due Date: Friday, March 29, 2013
You may attach additional information/documentation.

Mail To: Kathy Smiddy, Hall of Fame Nominations, APH, 1839 Frankfort Avenue, Louisville, KY 40206 - or email to ksmiddy@aph.org OR simply press the button below.

If electronically submitting, please remember to email (ksmiddy@aph.org) or mail in your three letters of support. If more than three letters are received, only the first three will be considered.

Please be patient! The form will take some time to process.
Please do not hit the 'submit' button more than once.

Hall of Fame: Leaders and Legends of the Blindness Field is a project of the entire field of blindness. It is curated by the American Printing House for the Blind, a 501(c)(3) tax exempt organization.