LDA - Louisiana Dental Association

2008 LDA Distinguished Service Award2008 LDA New Dentist AwardOfficial Call For NominationsPlease photocopy, complete, and/or forward this form together with any supporting exhibits to the LDA,7833 Office Park Blvd., Baton Rouge, LA 70809. All forms must be postmarked by November 1, 2007.Use additional pages if necessary. See requirements on the following page.NOMINATION FOR: (check one) ❑ NEW DENTIST AWARD ❑ DISTINGUISHED SERVICE AWARDNominee’s Name ________________________________________ Date of Birth ______________________Address ______________________________________________________________________________________Phone __________________________________________________ ADA# ____________________________Nominee has been a member of the ADA/LDA for years.____________________________________________Nominee’s local component. ____________________________________________________________________General description of nominee’s dental practice.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Nominee’s service to the LDA and ADA (i.e. service projects, committees). Briefly describe the nature of theservice, its value to the association and the year, beginning with the most recent.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Nominee’s service to the dental profession in general. Describe service to the profession other thanADA/LDA activities and the year(s). Include other dental organizations, projects.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Community Service. Describe activities in the community and the year(s) of service such as volunteer workat community dental clinic, school and church activities.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Other information you deem significant about the nominee.________________________________________________________________________________________________________________________________________________________________________________________On a separate page, please compose a two-paragraph statement of why you feelthis person deserves the award. Attach to this form for submission.36 LDA Journal