SEATA 2016 Hall of Fame Application FormPage 1 of 4

I.Nominee Name / Date of Application
Last / First / Middle / “Nickname”
NATA Membership # / BOC Certification # / Practicing / Retired / Deceased
II.Home Address / (Check Here if this is your Preferred Mailing Address) / NPI#
Address / City / State / Zip Code
Phone / Cell Phone / Fax / email
III.Office Address / (Check Here if this is your Preferred Mailing Address)
Organization or Institution Name / Title, Primary Occupational Role
Address / City / State / Zip Code
Phone / Cell Phone / Fax / email
IV.Birth Place:
City / State / Nation
Month / Day / Year / Arrived in Country (if applicable)
V.Family:
Spouse / Children & Ages (oldest first)
VI.Education: High School, College/University, degree(s), city/state, and years attended
School/College/University / Degree / City/State / Year(s) of attendance
VII.Professional Qualifications/Credentials
Certification and/or licensure / # (if applicable) / Year(s) From To
VIII.Employment History: Chronological descending order starting with current position.
Position / Organization / City/State / Year(s) From To
IX.Criteria for Consideration of Induction: District Service
1.SEATA Clinical Symposium & Members Meeting, Athletic Training Student Symposium or Athletic Training Educators Conference Attendance in chronological descending order starting with most recent (click HERE)
Meeting / Year / City / State
2.SEATA Clinical Symposium & Members Meeting, Athletic Training Student Symposium or Athletic Training Educators ConferenceChair/Coordinator in chronological descending order starting with most recent
Meeting / Year / City / State
3.SEATA Clinical Symposium & Members Meeting, Athletic Training Student Symposium or Athletic Training Educators ConferenceSpeaker in chronological descending order starting with most recent
Meeting / Topic/Title / Year
4.SEATA Standing Committee Membership in chronological descending order starting with most recent (Click HERE)
Committee / Position / Member or Chair / Year(s)
5.SEATA Ad Hoc Committee or Task Force Chair/Co-Chair in chronological descending order
Committee / Related details (if applicable) / Year(s)
6.SEATA Honors and Awards received in chronological descending order (Click HERE)
Honor or Award / Year
7.SEATA Annual Executive Board Meetings attended as State Organization President/Representative in conjunction with SEATA Clinical Symposium & Members Meeting(SEATA Past Leadership Click HERE and for Executive Board Minutes, Click HERE)
State Organization Represented / Year / City / State
8.SEATA Elected Officer Positions including Parliamentarian in chronological descending order (Click HERE)
Position / Year of Election / Year(s) of Service
9.State Athletic Training Association President
Organization / Year(s)
10.Other SEATA Service
X.Criteria for Consideration of Induction: Other Service
1.Any other Athletic Training contributions not recognized in any of the above categories
Submit completed form by December 15 prior to the induction year to: Bob Nevil, ATC, PT, Center for Sports Medicine, 2415 McCallie Ave , Chattanooga, TN 37404-3322 423-622-6200 Fax: 423-697-2025
(The following will be completed by the SEATA Hall of Fame Committee Chair)
Date Application Received by Chair / Signature of Chair

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