Nomination Form
Check one award per nomination form. (Separate nomination packages are required for each award and nominee.)
____ 2008 William G. Lennox Award ___ 2008 AES Service Award
Deadline June 1, 2008 Deadline August 1, 2008
____ 2008 J. Kiffin Penry - Excellence in Epilepsy Care Award
Deadline August 1, 2008
Name of nominee _____________________________________________________
Company Name _______________________________________________________
Mailing Address _______________________________________________________
City ___________________________ State ______________ Zip ______________
Phone ____________________________ E- mail___________________________
Profession/Occupation _______________________________________________
Name of Proposer ___________________________________________________
Company Name ____________________________________________________
Mailing Address ____________________________________________________
City _________________________ State ______________Zip ______________
Phone ____________________________________________________________
For Lennox Award Nominations please include nominee's CV.
Mail nomination form(s) and appropriate attachments to AES, 342 North Main Street, West Hartford, CT 06117-2507 or email to ctubby@aesnet.org .