Citizen Psycholgist Nomination Form

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ABPP Citizen Psychologist for Social Justice

Eligibility Criteria:

Nominees may come from any specialty within the American Board of Professional Psychology.
Nominees should meet or exceed the listed criteria for being a Citizen Psychologist for Social Justice.

Nominations:
• Any ABPP Board Certified psychologist can submit a nomination. Self nominations are welcome.

Nominations are accepted online only by completing this form by April 29, 2021 (Extended)

Date:	Today
Nominator's First Name:	Your first name
Nominator's Last Name:	Your last name
Nominator's Email:	Your email
Nominator's Occupation:
Nominator's Relationship to Nominee:	e.g., self, mentor, supervisor, fellow board member
Nominee's First Name:
Nominee's Last Name:
Nominee's Degree:	Highest degree earned
Nominee's Specialty Board:
Race and/or ethnicity:
Gender:
Social Justice Organization:	For Nominee
Title or Role in Organization:	For Nominee
Length of Service with Organization:
Brief description of how nominee meets the definition of Citizen Psychologist for Social Justice:	1500 words or less
Examples of activities that exemplify the nominee's work in this area:	1500 words or less
Please upload 1st letter of recommendation:	Submitted by someone familiar with and has cited their work related to Citizen Psychologist for Social Justice (does not need to be a psychologist)
Please upload 2nd letter of recommendation:	Submitted by someone familiar with and has cited their work related to Citizen Psychologist for Social Justice (does not need to be a psychologist)
Upload Nominee's CV:


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