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* 1. Nominee Information - Please provide the details of the individual you are nominating for the Membership Committee. 

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* 2. Nominator Name & Email (Note: Self-nominations are accepted)

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* 3. Nominee: How would you describe your ethnic identity?

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* 4. Nominee: How would you describe your racial identity?

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* 5. Nominee: Which of the following best describes you personally?

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* 6. Nominee Bio (500 words max)

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* 7. Nominee: What is the workplace setting where you spend most of your time (your primary place of employment)?

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* 8. Nominee Career Level

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* 9. How has the nominee been involved in AcademyHeatlh?

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