1.

Please complete the application completely.

Submitted by:

Question Title

* 1. Submitted by:

Please enter the Clinical-Research candidate information:

Question Title

* 2. Please enter the Clinical-Research candidate information:

Candidate's Academy membership number:

Question Title

* 3. Candidate's Academy membership number:

Please enter the education information.

Question Title

* 4. Please enter the education information.

Nominees should have made significant contributions in clinical dietetics/research in one or more of the following areas:
 Development of a special clinical nutrition program
 Development of patient/public nutrition education material
 Original contribution in clinical nutrition research
Please describe your contribution below.

Question Title

* 5. Nominees should have made significant contributions in clinical dietetics/research in one or more of the following areas:
 Development of a special clinical nutrition program
 Development of patient/public nutrition education material
 Original contribution in clinical nutrition research
Please describe your contribution below.

Please add any other information that supports the nomination for the Clinical-Research Excellence Award..

Question Title

* 6. Please add any other information that supports the nomination for the Clinical-Research Excellence Award..

Please submit information regarding your employer (if you are selected, a letter will be sent to your employer).

Question Title

* 7. Please submit information regarding your employer (if you are selected, a letter will be sent to your employer).

T