Leadership Recognition Application

Application and all supporting documents must be received on or before July 31 for consideration for this year. Awards are presented at our annual conference October 12-14, 2011 at the Wilderness Hotel and Golf resort in Wisconsin Dells. We hope to see you there!

Personal/Professional Info

First Name:

Last Name:

Title/Position:

Employer:

Date of Hire:

(Work) Address:

City:

State:

Zip Code:

(Work) Email Address:

Company CEO or President:

Please accept this application and the accompanying check payable to WHPRMS for my advancement to the following level in the WHPRMS Leadership Recognition program:

Have you already achieved a Leadership Recognition Level? If so, which level?

Certified:

Accredited:

Division A — Professional Membership & Participation

In this division, the applicant should list the years of membership in WHPRMS and all WHPRMS involvement, i.e., officer, committee chairperson or member, board member, etc. All other public relations or marketing organizations on a national regional, state or district level should also be listed. If you are applying for Accredited or Fellow status and there are no changes from your previous application, please indicate 'No Change' and go to the next Division.

Organization	Year(s)	Membership Status

Division B — Education

In this division, the applicant may accumulate points for the number of years of higher education completed. If you are applying for Accredited or Fellow status and there are no changes from your previous application, please indicate 'No Change' and go to the next Division.

College/University	Location	Dates Attended	Degree Earned

I am presently working on:

Division C — Experience

In this division, the applicant may accumulate points for public relations, marketing and related professional experience in a hospital or healthcare organization, a professional public relations or marketing firm, or as a business owner or freelancer.

Please indicate the approximate percentage of your time that is spent on the following functions. (The percentage should total 100%.)

%	Advertising
%	Community relations
%	Customer service
%	Development (fund-raising)
%	Editing publications
%	Event management
%	Government relations
%	Internal communications
%	Management/admin
%	Marketing
%	Market research
%	Media relations
%	New product development
%	Physical relations
%	Planning
%	Quality management
%	Social media
%	Teaching others
%	Website development
%	Volunteers/Auxiliary
%	OTHER
100 %	Total

Division D — Continuing Education

In this division, the applicant may accumulate points for continuing education at national, regional, state and WHPRMS seminars or conferences; at related university courses; and for teaching university courses, seminars and workshops.

List all public relations or marketing conferences, courses, seminars, and workshops attended, as a program participant or instructor, giving name of the conference/course, speaker or sponsoring organization, location and dates. If you are applying for Accredited or Fellow status and there are no changes from your previous application, please indicate 'No Change' and go to the next Division.

Name of Conference/Course	Speaker/Sponsor	Location	Date

Division E — Awards & Recognition

In this division, the applicant may accumulate points for awards received for public relations and marketing programs. List the awards and recognition received. Provide information on name of award, presenting organization and the date. If you have had any articles published, please list their titles and the name and date of the publication. If you are applying for Accredited or Fellow status and there are no changes from your previous application, please indicate 'No Change' and go to the next Division.

Award Name/Title of Article	Presenting Organization/Publication	Date

Division F — Evidence of Public Relations and/or Marketing Performance

Evidence of performance of each applicant is required. An additional 01-10 points may be awarded by the Leadership Recognition program based on the quality of marketing and public relations material submitted by the applicant for review. Material should be representative of the work of the applicant. Please attach a sheet with the following information for each project shared:

To what extent did the applicant do the work (planning, writing, concept, design, etc.) AND
How did the applicant measure success and what were the results

Please upload PDF's only.

Statement by Applicant

I hereby attest to the accuracy of the information contained in the application and understand that any false statement or misrepresentation I make may result in the revocation of this application. I authorize the Leadership Recognition program to make any inquiries that are necessary in ascertaining my fitness for advancement in the Leadership Recognition program, and I agree to abide by their decision.

Certified Status:

Accredited Status:

Fellow Status: