Please complete the application completely.

* 1. Submitted by:

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

* 3. Candidate's Academy membership number:

* 4. Please enter the education information.

* 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.

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

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