Fellows Nomination Form - ASET - The Neurodiagnostic Society

Please complete this online submission form in its entirety. You can either upload or type your written statement supporting the nomination. Nominations deadline is February 28, 2024. Please contact Kevin Helm [email protected] if you have any questions.

Part I Nominator Contact Information

Your Name: *

First

Last

ASET Member ID Number:

Phone:

Email: *

Part II Nominee Information

Name of Nominee: *

First

Last

Employer:

Employment Title:

Mailing Address:

Address Line 1

Address Line 2

City

State

Zip Code

Email: *

Phone:

Part III Required Documentation

Either submit or upload along with this completed online form, a brief typed statement (no more than 500 words) supporting the nomination by speaking to how the nominee meets the nomination criteria in general by having distinguished him/herself in service to ASET, service to the neurodiagnostic profession, and as an ambassador exemplifying and advancing the neurodiagnostic profession.

Typed Statement

Upload Typed Statement

Click or drag a file to this area to upload.

no more than 500 words

Submission

Completed form and statement supporting the nomination submitted by February 28, 2024. If you have questions please contact Kevin Helm at [email protected].