Intro Text APPLICANT INFORMATION Name Credentials CCM # (if applicable) Preferred Address Title Current place of employment Daytime Phone Email letters of recommendation letter of recommendation intro Letters of Recommendation letters of recommendation 1 Upload Upload requirementsOne file only.2 MB limit.Allowed types: pdf, doc, docx. letters of recommendation 2 Upload Upload requirementsOne file only.2 MB limit.Allowed types: pdf, doc, docx. Notice 01 If chosen, I agree to the use of my name and a promotional quote to market this program. Signature Date Case Management: A Legacy of Excellence Award Your application must include the information below. Please describe how you would use what you have learned to influence or inspire others. Please provide a specific example of innovation, leadership or collaborative skills. Will you be willing to speak at a future event, and /or agree to be profiled in any marketing materials on the importance of obtaining the CCM designation, and what it means to you personally? Have you ever worked for a profit, non-profit and or government agency? If so, what company and when? What is the most important role of today’s professional case manager? (40 words or less) What is the most important tool for effective client engagement? (40 words or less) How long have you been in case management? Describe your involvement in continuing education pursuits as a student or teacher. Please identify your key work accomplishments in Case Management. Please identify any leadership/membership positions and professional involvement you have had in case management organizations or groups. Describe your role as a mentor to others. Describe your most significant mentor and how he or she influenced your career? What do you hope to achieve as a result of receiving this award? Essay: Describe, in 350 words or less, your reasons for applying for the award. Please describe your vision for case management and how it would be supported by this educational event. Upload Upload requirementsOne file only.8 MB limit.Allowed types: pdf, doc, docx. Licensure and Employment Information State Licensed RN License Number Date of Expiration of RN license Select the category of your work experience I have 24 months of case management experience. During my case management employment experience, my supervisor was a Certified Case Manager (CCM), and my supervisor was certified for at least 12 months during my employment. I have 12 months of acceptable full-time employment Employment Experience Title Start Date End Date Hours Per Week Employer Name Employment Experience Title Start Date End Date Hours Per Week Employer Name Submit