AWARD NOMINATION FORM
Which Award are you submitting a nomination for? (Please select)
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DISTINGUISHED SERVICE AWARD - awarded to a nominated member who, for a substantial period, has rendered distinguished service to the Association or to the dental profession.
SERVICE MEDALLION - awarded to a nominated member who, for a substantial period, has rendered valuable service to the Association or to the dental profession.
LIFE MEMBERSHIP - financial members can submit the name of another member, who has rendered exceptionally distinguished service to the Association or to the dental profession for consideration at the Annual General Meeting.
AWARD OF MERIT - awarded to any person other than a dentist, nominated by a financial member, and who, for a substantial period, has rendered exceptionally distinguished service to the Association or to the dental profession.
HONORARY MEMBERSHIP - can be awarded to any person, nominated by a current member, who has rendered honourable or substantial service to the dental profession, in any part of the world and in any of the sciences allied to dentistry.
EDWARD WALTER HAENKE RURAL PRACTITIONER AWARD - The award is established to honour the work of an exceptional rural and remote dentist who has significantly contributed to their community / displays exemplary commitment to rural/remote oral health. The award recipient must be a current ADAQ member, have been a member of ADAQ throughout (most) of their career and exemplify the ‘rural dentist’ commitment and dedication to their community.
YOUR INFORMATION
ADAQ Member Number
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Personal details
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Title
First Name
Last Name
Post Nominals
Phone Number
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Area Code
Phone Number
Email
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What is your relationship to the nominee?
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NOMINEE DETAILS
Nominee's personal details
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Title
First Name
Last Name
Post Nominals
Phone Number
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Area Code
Phone Number
Email
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Reason for nomination
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Briefly explain why you think the nominee should receive this award or honour this year
Submission
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How has the nominee demonstrated the merit and commitment to excellence?
Please detail your relationship to the nominee below
Do you need to declare a conflict of interest?
Please attach any supporting documents
Browse Files
Must include a CV, resume or biography and objective proof, e.g. research links, pictures, media articles, patient testimonials.
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Declaration
I declare that the information submitted in the form is true and correct and I have disclosed any conflicts of interests.
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