Contact Details and DemographicsName *First & Last NameStreet Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweEmail Address *Phone *ACS Membership Number *GenderGenderMaleFemaleNon-binaryI prefer not to say.Racial-Ethnic OriginRacial-Ethnic OriginAfrican American/BlackAmerican Indian/Alaska NativeAsianCaucasianHispanic/LatinoNative Hawaiian/Pacific IslanderI prefer not to say.Do you consider yourself to be someone with a disability?DisabillityYesNoI prefer not to say.EligibilityAge as of January 1, 2024 *Name of Current Institution *Title of Current Position *Years in Current Position *Current Status *Undergraduate StudentGraduate StudentPostdoctoral StudentIndustry/Government/Non-ProfitOtherCitizenship Status/Visa Status *US CitizenUS Permanent ResidentStudent VisaWork VisaNone of the AboveResidency *I reside in the USI do not reside in the USApplicationUpload CV/Resume (PDF or Docx only) *Choose FileNo file chosenDelete uploaded fileDescribe your leadership/volunteer experience in the ACS (ACS student chapter, local section, regional meetings, national meetings, etc.). *Describe your leadership/volunteer experiences in other professional societies, organizations, universities/colleges. *Describe your leadership experience in your current position and/or potential leadership opportunities. *Describe your experience in mentoring another person. *List your academic achievements, awards, etc. *List oral and poster presentations given within the past 5 years. Please indicate invited talks. *List publications published within the past 5 years. *List professional meetings you have attended within the past 2 years. *List professional development courses you have taken. *Provide a short biography for publication on the PROF website and/or social media promotions. *Please provide the name of the individual who will be sending in a recommendation on your behalf. Letters of Recommendation should be sent to awards@acsprof.org. *By selecting this box, I acknowledge that accepting this award will include sharing my name and likeness with the Division of Professional Relations and the ACS PRIDE subdivision. The purpose of this use is to further promote the award and the recipient and help grow their professional career. *YesYesNoI certify that the information provided is accurate and correct to the best of my knowledge. *ConfirmYour Initials *Date *Submit Application
