NSSLHA Honors Program Application

Nominee(s)' Information

Area of Consideration:*

First Name of Nominee (if individual being nominated):

Last Name of Nominee (individual or institution):*

Nominee(s)' E-mail (individual or contact person of a chapter):

ASHA Account Number:

NSSLHA Account Number:

Chapter Advisor's First Name:*

Chapter Advisor's Last Name:*

Chapter Advisor's ASHA Account Number:

Chapter President's First Name:*

Chapter President's Last Name:*

Chapter President's NSSLHA Account Number:

Please describe how the advisor's, chapter's, or individual member's work has advanced the mission of NSSLHA (500 word max).*

Nominator's Information

Nominator's First Name:*

Nominator's Last Name:*

Nominator's Position:*

University Name:*

Mailing Address (correspondence will be mailed to this address):*

City:*

State:*

Zip Code:*

Phone Number:*

E-mail:*

One of NSSLHA's goals is to have its membership represent the multicultural diversity of the American society. Please let us know if the nominee meets one of these racial/ethnic categories.