Pennsylvania Academy of Nutrition and Dietetics
Keystone Award Application
Nomination Data Sheet

PURPOSE

The purpose of the Keystone Award is to give recognition to the Pennsylvania dietitian/s who have, through leadership ability, demonstrated exemplary professional standards to serve and advance the aims of the Pennsylvania Academy of Nutrition and Dietetics. This award is presented to a maximum of two members of the Pennsylvania Academy of Nutrition and Dietetics each year.

CRITERIA

To qualify as a nominee to receive this award, an individual must:

1. Be a registered dietitian and member of the Academy of Nutrition and Dietetics for 10 years or longer.

2.Have contributed to the Pennsylvania Academy of Nutrition and Dietetics through active participation and service at the state and district level and have provided support in exceptional ways.

3.Have demonstrated leadership and professional ability.

4.Be dedicated to the high standards of the profession.

5.Have initiated efforts to advance the status of the profession.

6.Have participated in activities to improve the states of human beings.

7.Have community service and/or outreach activities.

8.Perform in areas of consultation or advisory work with allied professions.

9.Be recognized by colleagues and/or related organizations.

10.Be published/original works.

11.Not have been selected previously for a higher award.

INSTRUCTIONS

Nominations for awards will be limited to no more than 10 pages (not including letters of recommendation and CV or resume) and must be scanned and emailed to the current Chair of the State Nominating Committee:

2016 State Nominating Committee Chair, Carly Pelchen at:

Please simply list your accomplishments and confirm that you have not have been selected previously for a higher PANDaward.Publications can be listed with a sentence about where the committee can find them.The completed “Nomination Sheet” at the end of this document must accompany each application.Please attach CV or resume at the end of this document as well as letters of recommendation.

The Awards and Scholarship Committee of the Pennsylvania Academy of Nutrition and Dietetics will review each application for award determination. The KeystoneAward will be announced at the PA Academy of Nutrition and Dietetics Annual Meeting and Exhibition.

Please complete each section. If a particular criterion does not apply to the nominee, please write N/A (not applicable) in the space. Application must be typed, scanned, and emailed as per the instructions above.

NAME OF NOMINEE ______CREDENTIALS:

Last MI First

HOME ADDRESS ______

Street City State Zip

BUSINESS ADDRESS ______

Street City State Zip

HOME PHONE BUSINESS PHONE

ACADEMY MEMBERSHIP #______ACADEMY MEMBER SINCE ___

PROFESSIONAL MEMBERSHIP AND PARTICIPATION
Positions Held Dates

Pennsylvania Academy of Nutrition and Dietetics
Keystone Award Application
Nomination Criterion
Please complete each section. If a particular criterion does not apply to the nominee, please write N/A (not applicable) in that space.
Criterion 1
Dedication to high standards of the profession

Criterion 2
Initiation of efforts to advance the status of the profession

Criterion 3
Activities to improve the status of human beings

Criterion 4
Community services/outreach

Criterion 5
Consultation or advisory work

Criterion 6
Recognition by colleagues and/or related organization

Criterion 7
Publications/original works (Cite any applicable works)

Pennsylvania Academy of Nutrition and Dietetics
Keystone Award
Nomination Sheet
PERSON MAKING THE NOMINATION ______
ADDRESS ______
Street City State ZIP
HOME PHONE ______BUSINESS PHONE______
NAME OF NOMINEE ______
REASON FOR NOMINATION:
______
Signature of District President Date

* Please attach CV or resume file here, at the end of your application packet.

* Please attach letters of recommendation following CV.

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