Undergraduate Award Program Application-US

Undergraduate Award Program - US Physical Delivery

United States institutions who would like to receive a paper certificate and award letter by US Mail are required to complete this form. While we plan to send you the official award items by April 30th, once the form is submitted, you are welcome to immediately recognize the student as you deem appropriate. Upon receipt of the award letter, the student awardees will be able to complete an application to join the Division free for one year.

"*" indicates required fields

New starting in 2022: All schools may nominate a second extraordinary student when they include consideration in areas such as race, ethnicity, nationality, socioeconomic status, non-traditional gender identification or sexual orientation, religious affiliation, or (dis)ability. Please note that data obtained by ACS on the gender of Bachelor’s level chemists indicates that women and men are graduating at nearly equal numbers since 2001. Therefore, the Division has removed gender as criteria for a second nomination for this award.

Nominator (Your) Information

Is this your institutions First or Second Nomination?*

Nominator First Name*

Nominator Last Name*

Nominator's Email*

Nominator's Phone*

Which best describes your role in the nomination process for your department:*

If other is selected, please explain in the text box provided

URL to your Department Homepage*

Certificate information

Be sure to double check spelling, capitalization, and punctuation. Student and University names will appear EXACTLY as you enter them.

Name of College or University, exactly as it should appear on the certificate*

Student's name exactly as it should appear on the certificate*

Student's Email*

We would like this for our records, at this time we do not have plans to contact the student about this award.

Shipping Address

Please answer the following questions, we will organize the address per postal service formatting requirements. If you are unsure please use the contact us form. for support. The Institution Name will automatically be included (unless noted in special routing instructions)

Department Name, Building, and Room Number (if Applicable)*

i.e. Chemistry Department - Room 2529 or Starr Science Building

Street address and /or box number*

i.e. 930 N. University or PO Box 4823

Special Routing Instructions

e.g. c/o or Attn:

City*

State*

Zip Code*

I certify that my college/university will only give the appropriate number of awards per academic year and that the student named above meets my college/university's criteria for the award.*

I Agree

Comments

This field is for validation purposes and should be left unchanged.