Name (as it should appear on the award)*
First Last
Will you be in attendance in person at the Awards Ceremony on June 29 in Louisville during the ASCLS Joint Annual Meeting?*
- Yes
- No
Will someone accept the award on your behalf during the ceremony in Louisville??
- Yes
- No
Name of Person Accepting
First Last
Email of Person Accepting
Please submit a photo(s) of yourself to share during the Awards Ceremony
Drop files here or
*Please name your file with your first and last name.
If you or a proxy are unable to attend the Awards Ceremony, your award will be mailed to the address on this form after the Joint Annual Meeting.
Contact Information for Award Recipient
Must be valid as of July 1, 2021.
Address
Street Address City State ZIP Code
Email*
Alternate Email
Phone
Alternate Phone

ASCLS Awards Ceremony RSVP

Contact Information for Award Recipient