Class of 2024-2025 Academy CECI2 Nominations Form
Full Name
Email
Business Name
Adress
Adress 2
City
State
Zipcode
Nominator
Full Name:
Nominator
Institution:
Nominator Email:
Nominee
Full Name (including middle names/initials and professional degrees, and in the way it should be listed on all CECI² materials):
Nominee
Institution (please write as it should be listed on award materials):
Nominee
Cell Phone: (needed for larger group communications):
Nominee
Email:
Academic Rank of Nominee:
Nominee's Membership in Other Professional Societies (please list below, ex: RSNA, ISMRM, ACR, etc.):
Nominator
Please confirm that your Institution is willing to sponsor the travel expenses for this investigator to participate in Level 2 of this program (in-person in Washington DC). Estimated cost, $1,500:
Yes
No
Nominator
Please describe why your nominee is a good fit for this council:
Nominee
Please explain why you wish to participate in this virtual programming, including information on how it fits into your professional goals:
Nominee
Please describe your research interests in layman terms. Please also explain potential topics and focus for your ongoing research priorities, you will be discussing these throughout various sessions and workshops. It will be incredibly helpful for our planning efforts to know what your research is focused on:
Nominee
What types of grant funding have you received so far:
As nominator, I certify that I have personally confirmed that the information in this nomination worksheet is correct:
Yes
No
Contact Information