ANCOR Foundation Legacy Leader Nomination Form

Foundation

The ANCOR Legacy Leader Circle recognizes the accomplishments of leaders across the country - "pioneers" who having positively impacted the disability field. You may nominate ANCOR members or non-members.

The nominator will be contacted regarding the status of the committee selection. If your nominee is selected, the full contribution must be received prior to the award is received.

If a person does not know he or she is nominated, the nominator must ensure a media release is signed by the Honoree no later then one week after the award is presented.

The ANCOR Foundation is a 501(c)3 charitable organization. Contributions made to the Legacy Leaders program are tax-deductible.

Nominator Information
Numbers only. No parentheses or dashes.
Nominee Information
Numbers only. No parentheses or dashes.
If your nominee is not an ANCOR member, please describe, in detail, his or her past or current relationship and/or collaborations with ANCOR, if any. (250 maximum word length)
GIF or JPG only. Max file size 2 mb. If you are experiencing issues attaching a photograph to this form, then send it via e-mail to dlangseth@ancor.org. For publicity purposes, submit a digital photograph (headshot) of the nominee.
$
Payment
Must be received prior to an award being presented. 50% of the nomination cost is placed in the Endowment and 50% is allotted for Leadership Development activities.
The nominator will be contacted regarding the status of the committee selection. If your nominee is selected, the full contribution must be received prior to the award being presented.
By completing this application and clicking the "submit" button, I understand that I am responsible for paying at least $1,000 to recognize the individual nominated for this distinction. I further certify that, to the best of my knowledge, this individual has not been convicted of Medicaid/Medicare fraud or any other criminal activity.