ACEM Medal nomination

ACEM Medal nomination
Form No: COR588
Last Revised: February 2025
Version: v4
Nominee
We, the undersigned, nominate the ACEM Fellow named below for the consideration of * for the award of the ACEM Medal.
Nominee name*

First NameLast Name
We have read the ACEM Medal Policy (AH371) associated with the award, and are of the view that the nominee meets the requirements for consideration of the award. As required, a citation in support of the nomination accompanies this Nomination Form.

We declare that we meet the criteria described in the policy to enable this nomination to be made and are aware that the nomination will ordinarily be considered in the first instance by either CAPP or COE, as applicable, with a majority vote in support of the nomination required to enable the nomination to be forwarded to the ACEM Board for consideration.
Nominators

Proposer
Nominator name*

First NameLast Name
Nominator email*
example@example.com
Nominator signature*

Clear
Date*

DayMonthYear
Date
Please tick as appropriate. The proposer and at least one of the other two must be FACEM members of the Council from which the nomination is being made or members of the Board as applicable. Where the third endorser is not a member of the Council from which the nomination is being made or the Board, as applicable, they must be a FACEM in good standing with the College, who has sufficient professional association with and knowledge of the nominee and their contributions to the College to provide detailed support for the nomination. I am a:*

Board memberFACEM member of CAPPFACEM member of COE
Supporters

These details will be used to notify the supporters to complete their section of this form
Supporter 1 name*

First NameLast Name
Supporter 1 email*
example@example.com
Supporter 2 name*

First NameLast Name
Supporter 2 email*
example@example.com
Citation
A citation in support of the nomination (not exceeding 400 words) must accompany the nomination. Please provide the citation below.*

0/400
Submission
This Nomination Form, including the citation in support of the nomination, must be submitted by no later than 5pm (AEST) on Monday 5 May 2025.

Supporter 1
Supporter 1 name

First NameLast Name
Supporter 1 signature

Clear
Date

DayMonthYear
Date
Please tick as appropriate. The proposer and at least one of the other two must be FACEM members of the Council from which the nomination is being made or members of the Board as applicable. Where the third endorser is not a member of the Council from which the nomination is being made or the Board, as applicable, they must be a FACEM in good standing with the College, who has sufficient professional association with and knowledge of the nominee and their contributions to the College to provide detailed support for the nomination. I am a:

Board memberFACEM member of CAPPFACEM member of COEFACEM
Submission
This Nomination Form, including the citation in support of the nomination, must be submitted by no later than 5pm (AEST) on Monday 5 May 2025.

Supporter 2
Supporter 2 name

First NameLast Name
Supporter 2 signature

Clear
Date

DayMonthYear
Date
Please tick as appropriate. The proposer and at least one of the other two must be FACEM members of the Council from which the nomination is being made or members of the Board as applicable. Where the third endorser is not a member of the Council from which the nomination is being made or the Board, as applicable, they must be a FACEM in good standing with the College, who has sufficient professional association with and knowledge of the nominee and their contributions to the College to provide detailed support for the nomination. I am a:

Board memberFACEM member of CAPPFACEM member of COEFACEM
Submission
This Nomination Form, including the citation in support of the nomination, must be submitted by no later than 5pm (AEST) on Monday 5 May 2025.
Should be Empty:

Nominee