2021-2022 BGC CIH Impact Award Nomination

Nomination Form

The BGC® Impact Award is awarded to a Certified Industrial Hygienist® or Certified Associate Industrial Hygienist® who has made a significant contribution to the practice of occupational and environmental hygiene.

Note: this form is for the Impact Award. If you are trying to nominate for the Lifetime Achievement Award, please click here: LAA Nomination Form

Question Title

* Nominee’s Information (the person being nominated)

Name *

Title

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Daytime Phone Number *

Question Title

* Certification Type and Certification Number (Please Note: To be eligible for this award, the nominee must have been a BGC® Diplomate in good standing for less than 20 years.)

Certification Number

Year Certified

Question Title

* Please upload the CV or resume for the person you are nominating

PDF, DOC, DOCX file types only.

Choose File

Using the box below, explain how the nominee’s accomplishments, work, and contributions resulted in a significant positive impact on the profession through a project, series of projects, or initiative that has been completed or was ongoing within the last 5 years.

Question Title

* Written Justification

Question Title

* NOMINATOR:
By typing my name below I certify that the above information is true and accurate to the best of my knowledge.

Name *

Title

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Daytime Phone Number *

Question Title

* Nominee’s Information (the person being nominated)

Question Title

* Certification Type and Certification Number (Please Note: To be eligible for this award, the nominee must have been a BGC® Diplomate in good standing for less than 20 years.)

Question Title

* Please upload the CV or resume for the person you are nominating

Question Title

* Written Justification

Question Title

* NOMINATOR:By typing my name below I certify that the above information is true and accurate to the best of my knowledge.

* NOMINATOR:
By typing my name below I certify that the above information is true and accurate to the best of my knowledge.