Nomination Form
Check one award per nomination form. (Separate nomination packages are required for each award and nominee.)
____ 2012 William G. Lennox Award ___ 2012 AES Service Award
Deadline June 1, 2012 Deadline August 6, 2012
____ 2012 J. Kiffin Penry - Excellence in Epilepsy Care Award
Deadline August 6, 2012
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 and a letter of recommendation.
Please send electronic package of nomination form(s) and appropriate attachments to Cheryl-Ann Tubby at ctubby@aesnet.org .