Wisconsin Psychological Association

* Name:

* Direct Phone:

* Email Address:

* WPA Membership Status:

WPA Member
WPA Non-Member

* Nomination Type:

Self Nomination
Nomination of Other

Name of Nominated Individual: Fill in this portion if this is a nomination for someone other than yourself.

Phone Number (if known): Fill in this portion if this is a nomination for someone other than yourself.

Email Address (if known): Fill in this portion if this is a nomination for someone other than yourself.

WPA Membership Status Fill in this portion if this is a nomination for someone other than yourself.

WPA Member
WPA Non-Member
Unknown

* Program and Institutional Affiliations

* Upload a one-page, brief letter highlighting nominee’s contributions in promoting understanding and respect for diversity in psychological practice, research, service and/or advocacy.

If self nominating, upload curriculum vitae. Note: If nominating someone else, they will be asked to submit theirs to the WPA office.

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DEI Award Nomination

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