APTA 2016 Honorary Membership Nomination Form
This form is in accordance with: Honorary Membership Proposal Submissions BOD R09-09-05-07
The following person is nominated by the
Chapter for consideration as an Honorary
Member of the American Physical Therapy Association:
Nominee Contact Information:
Name:
Mailing Address:
Phone:
E-mail:
Nominating Chapter Contact:
Name:
Mailing Address:
Phone:
E-mail:
Supporting Documents – Please include the following:
 Letter of nomination (Sample Nomination Letter – See Appendix A)
 Curriculum vitae or resume (Sample Curriculum Vitae – See Appendix B)
 Proposed resolution language (Sample Resolution Language – See Appendix C)
 You may also include other appropriate background materials
Please send the nomination packet via one of the following:
 E-mail: honorsandawards@apta.org
 Fax: 703/706-8536
 Mail: APTA, Attn: Honors and Awards/Member Services
1111 N Fairfax Street, Alexandria, VA 22314 -1488
All materials must be received on or before December 1, 2015.
Signature of Chapter President
Page 1 of 12 – APTA Honorary Membership Application
Date
Appendix A
Sample Nomination Letter
Note: The names used in this letter are fictitious
Date
APTA Board of Directors
1111 N Fairfax Street
Alexandria, VA 22314-1488
RE: Nomination of Bill Jones, PhD, for Honorary Membership in the American Physical Therapy
Association (APTA)
Dear Board of Directors:
The [insert chapter name] is pleased to support the nomination of Bill Jones, PhD, for
consideration of Honorary Membership in APTA. Dr. Jones’s contributions to the profession of
physical therapy are significant to the profession, national in recognition and scope, and of
unique quality.
Dr. Jones’ has made the following contributions to physical therapy: [In this section, please
discuss the depth and breadth of the contributions].
Thank you for your consideration and support of the nomination of Bill Jones, PhD, for honorary
membership in the APTA.
Sincerely,
Vincent Thomas, PT, DPT
[Insert title at chapter]
Page 2 of 12 – APTA Honorary Membership Application
Appendix B
Sample Curriculum Vitae
Note: A curriculum vitae is an account of one’s career and qualifications
BIOGRAPHICAL
Name:
Home Address:
Birth Date:
Social Security #:
Business Address:
E-mail Address:
Business Phone:
Fax:
Cellular Phone:
EDUCATION
List all post-secondary education completed in reverse order:
 Institution name
 Institution address
 Degree earned, year of graduation/completion
 Concentration of study
 Dates attended
Dates Attended
Degree and Year
Earned
Concentration of
Study
Institution
Institution Address
Dates Attended
Degree and Year
Earned
Concentration of
Study
Institution
Institution Address
Page 3 of 12 – APTA Honorary Membership Application
LICENSURE AND CERTIFICATION
List all licenses and certifications you hold. Include:
 Licensing or certifying organization (state board, professional organization, etc.)
 License or certificate number
 Dates
Certifying Organization
License / Certificate Number
Dates Valid
*Maintain separate hard copy files of all certificate and license information
PROFESSIONAL EXPERIENCE
List relevant work experience including positions which are academic, clinical, consultative,
administrative, and CI experience. List information in reverse chronological order and include:
 Dates
 Title
 Organization name
 Address
 Supervisor’s name and telephone
 Job responsibilities/accomplishments
o Direct patient care responsibilities
 Types of patient/client and diagnoses/treatments
 Total clinical hours
o Indirect patient care responsibilities
 Administration
 Education
 Research
 Special assignments/projects
Dates
Dates
Title
Organization Name
Address
Description
 Direct Patient Care
 Indirect Patient
Care
Supervisor
Name/Telephone
Title
Organization Name
Address
Page 4 of 12 – APTA Honorary Membership Application
Description
 Direct Patient Care
 Indirect Patient
Care
Supervisor
Name/Telephone
PROFESSIONAL DEVELOPMENT*
Include professional development/continuing education completed. List information in reverse
chronological order:
 Workshop title / CE title
 Date(s)
 Location (City, State)
 Number of Continuing Education Units (CEUs)
 Presenter
 Sponsor and address
 Length of presentation
Date(s)
CEUs
Title
City, State
Sponsor & Address
Presenters
Date(s)
CEUs
Title
City, State
Sponsor & Address
Presenters
*It is essential to maintain a permanent record of your CE documentation. Documentation includes
course title, description, objectives, schedule and certificate of completion.
TEACHING ACTIVITIES
COLLEGE / UNIVERSITY COURSES*







Course Title
Date
Location
College/University
Length of presentation
Number of continuing education units/contact hours
Topic, description & objectives for all portions you presented
Date
Credit Hours
Course Title
Location
College/University
Page 5 of 12 – APTA Honorary Membership Application
Length of Course
Topic (if different from
course title)
Description &
Objectives
Date
Credit Hours
Title
Location
College/University
Length of Course
Topic (if different from
course title)
Description &
Objectives
*Maintain separate records of involvement in student clinical education (names of students, dates of
affiliation, level, and area of practice)
POST-GRADUATE CONTINUING EDUCATION*
Date
CEUs
Contact Time with
Learners**
Title
Location
Sponsor
Topic,
Description
and Objectives
Date
CEUs
Contact Time with
Learners**
Title
Location
Sponsor
Topic,
Description
and Objectives
*It is essential to keep a permanent record of your presentation(s). Documentation includes all of the
above plus summary of participant evaluations.
**Contact time is the actual amount of time that you are presenting and/or interacting with the
learners.
Page 6 of 12 – APTA Honorary Membership Application
CLINICAL INSTRUCTION
List roles/activities related to clinical education of PT’s and PTA’s at all levels of education.
 Dates
 Role/position
 Summarized data
o Number of students
o Level of instruction
o Duration of affiliation
Dates
Role
Summarized Data (yearly basis)
*Maintain separate records of involvement in student clinical education (names of students, dates of
affiliation, level, and area of practice)
COMMUNITY-BASED EDUCATION
Date
Title
Location
Sponsor
Length of Presentation
Description
Date
Title
Location
Sponsor
Length of Presentation
Description
Page 7 of 12 – APTA Honorary Membership Application
SCHOLARLY ACTIVITIES
PROFESSIONAL PRESENTATIONS
Include platform or poster presentations at professional meetings and invited lectureships such as
McMillan Lecture or Maley Lecture:
 Title of presentation
 Date
 Location
 Length of presentation
 Brief description
 Sponsors
Date
Title
Location
Sponsor
Length of Presentation
Description
Date
Title
Location
Sponsor
Length of Presentation
Description

PUBLICATIONS
Authorship of book chapters, peer reviewed journal articles, research abstracts, reviews or
commentaries and case study or case study reports.
o Use AMA format for full bibliographic reference
o A useful website for AMA citation styles is:
http://healthlinks.washington.edu/hsl/styleguides/ama.html
Sample AMA format citation for Journal Article:
Noonan V, Dean E: Submaximal exercise testing: clinical application and
interpretation. Phys Ther 2000 Aug;80(8):782-807

Professional activities related to scholarship includes grant proposals, writings you have edited
such as books, peer reviewed journals, and submissions to outcomes database such as Hooked
on Evidence, and manuscript reviews. List in reverse chronological order:
o Role (editor, reviewer, board member, grant writer)
o Title of work
o Author (if applicable)
o Publication date
o Provide bibliographic reference or brief description of work
Page 8 of 12 – APTA Honorary Membership Application
Role
Title of Work
Author
Publication Date
Bibliographic
Reference/Brief
Description
Role
Title of Work
Author
Publication Date
Bibliographic
Reference/Brief
Description
RESEARCH ACTIVITIES
List current research projects:
Title
Description
Length of Project
Responsibility Within Project
Funding Source
Amount of Funding
Title
Description
Length of Project
Responsibility Within Project
Funding Source
Amount of Funding
Page 9 of 12 – APTA Honorary Membership Application
PROFESSIONAL MEMBERSHIP & ACTIVITIES
List all professional or scientific societies that you are a member of. Include the following:





Dates
Association or society name
Membership status
Indicate if you held a position in addition to being a member and the years you held position
Brief description of accomplishments
Dates
Dates
Association/Society
Membership Status
Positions/Offices Held and Dates
Brief Description of Accomplishments
Association/Society
Membership Status
Positions/Offices Held and Dates
Brief Description of Accomplishments
PROFESSIONAL SERVICES
List committee membership, association activities, content expert/consultant, or other profession
related activities. Information listed should be organized in reverse chronological order and include:
 Dates
 Position held/title
 Committee name/organization
 Description (bulleted)
o Accomplishments
Dates
Title/Position
Committee
Name/Organization
Description
Accomplishments
Dates
Title/Position
Committee
Name/Organization
Description
Accomplishments
HONORS/AWARDS
List honors and awards you have received throughout your educational and professional work
experiences. Examples of this may be university dean’s list, professional or academic fraternities,
and organization recognition. Information to include is:

School/organization bestowing honors/awards

Brief description of award

Date received
Page 10 of 12 – APTA Honorary Membership Application
Date Received
School / Organization
Description of Honor/Award
Date Received
School / Organization
Description of Honor/Award
UNIQUE QUALIFICATIONS
List any additional qualifications you possess that may compliment your professional knowledge and
skills such as sign language, fluency in a foreign language, and advanced computer literacy.
Page 11 of 12 – APTA Honorary Membership Application
Appendix C
Sample Resolution Language
Formatting Notes:

A resolution should always begin with the words “ELECTION TO HONORARY MEMBERSHIP IN
THE AMERICAN PHYSICAL THERAPY ASSOCIATION:” in all capital letters followed by the
nominee’s name.

In the “Whereas” section - the first letter of “Whereas” and first letter of the word following
“Whereas” is always capitalized. “Whereas” is always followed by a comma, and sentences
starting with “Whereas” should end with a semi-colon.

At the end of the clause immediately preceding the last “Whereas” statement of the resolution,
place the word “and” after the semi-colon followed by a comma.

The first letter of “Resolved” and first letter of the word following “Resolved” is always
capitalized. “Resolved” is always followed by a comma, and the sentence should end with a
period. There may be more than one “Resolved” in a resolution.
ELECTION TO HONORARY MEMBERSHIP IN THE AMERICAN PHYSICAL THERAPY ASSOCIATION: [insert
name of nominee – e.g. Bill Jones, PT, PhD]
Whereas, Dr. Bill Jones has made significant contributions to the practice of physical therapy;
Whereas, Dr. Jones has co-authored over 100 peer reviewed articles with physical therapists; and
Whereas, Dr. Jones was instrumental in conducting research in ten studies that contributed significantly
to the understanding of a major illness commonly seen in physical therapist practice; and,
Whereas, Dr. Jones has advocated for and won increased funding for physical therapy research
Resolved, That Dr. Bill Jones be elected as an Honorary Member of the American Physical Therapy
Association.
Page 12 of 12 – APTA Honorary Membership Application