Award Nomination Form Deadline for 2018 Award Nominations: September 7, 2018 Please indicate category: 2018 Humanitarian Service Award 2018 Outstanding Service Award 2018 Guest of Honor 2018 New Dentist Leadership Award (A candidate must have graduated from dental school on or after Jan. 1, 2008) Name: ADA Number: Date of Birth: Address: City/State/Zip: Telephone: Email: Please provide a summary of the candidate’s qualifications in the following categories, as appropriate: Identify leadership qualities/traits: Describe leadership initiatives the candidate has demonstrated: Describe role model traits the candidate has shown, as well as examples of mentor activities: Provide examples of contributions that have helped organized dentistry to achieve its goals: (Not required for Humanitarian Service Award.) Has the candidate made an impact on the practice of dentistry in the community? Indicate offices held, committee appointments, programs implemented and honors received:
Award Nomination Form Deadline for 2018 Award Nominations: September 7, 2018 Please indicate category: 2018 Humanitarian Service Award 2018 Outstanding Service Award 2018 Guest of Honor 2018 New Dentist Leadership Award (A candidate must have graduated from dental school on or after Jan. 1, 2008) Name: ADA Number: Date of Birth: Address: City/State/Zip: Telephone: Email: Please provide a summary of the candidate’s qualifications in the following categories, as appropriate: Identify leadership qualities/traits: Describe leadership initiatives the candidate has demonstrated: Describe role model traits the candidate has shown, as well as examples of mentor activities: Provide examples of contributions that have helped organized dentistry to achieve its goals: (Not required for Humanitarian Service Award.) Has the candidate made an impact on the practice of dentistry in the community? Indicate offices held, committee appointments, programs implemented and honors received:
2018-Award-Nomination-Form-2.docx