Marianne Marcus Award Nomination Form

Marianne Marcus Award Application

"*" indicates required fields

Name*

Prefix First Last

Institution*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is this address for:*

Home

Institution

Email*

Phone

What is your race/ethnicity?

How did you hear about the Marianne Marcus award?*

If through a mentor/colleague, please provide his/her name

Current job/title

Given the criteria of this award, what qualifies you for this award? Check any of the following that apply to you.

You are from a minority or underrepresented background, including Latino, African American, woman, LGBTQ individual, and/or from a traditionally minority institution

You are specializing in substance use / addictions

You are in a position to disseminate knowledge and skills from the national meeting to colleagues, students or mentees

You have submitted an abstract (poster or podium).

In the space provided below, in 300 words or less, please describe:

Your current focal area/interests in substance use, how this fits with your current professional / student role
If you indicated you are from a minority group or a minority institution, please describe
Your goals as a nurse leader in this specialty area
Why you are interested in attending the AMERSA National Conference and how you will disseminate what you learn to others

Personal Statement

Please include your CV or Resume*

Max. file size: 256 MB.

Please include a Letter of Recommendation*

Max. file size: 256 MB.

Please contact annie.potter@bmc.org with any questions.

Phone

This field is for validation purposes and should be left unchanged.