Keystone Honor Nomination Form

Keystone Honor Nomination Form
Please complete all sections of this form. Incomplete submissions will not be considered.
Primary Nominator Information
Contact Full Name*
Contact Email*
example@example.com
Contact Phone*
Please enter a valid phone number.
If there are additional nominators, list their contact names and emails here
OTA Keystone Honor Nominee Information
Nominees Full Name*
Current Position/Title
Institution/Organization
Contact Email
example@example.com
Impact Statement Describe how the nominee has made an extraordinary impact in the field of orthopaedic trauma (max 500 words)*
Supporting Evidence Provide specific examples of achievements initiatives or contributions. (Send supporting documents if necessary)*
References: Provide the names and contact information of a minimum 2-3 individuals who can speak to the nominee's impact.
1*
2*
3
Pledge Commitment: 100% of OTA Keystone Honor Funds will be used solely to support OTA Research and Education. Alternatively, if a donor prefers to direct funds to a specific OTA initiative, request to direct these funds to specific OTA initiative may be considered
Date of Intended Initial Nomination Contribution of $20,000: *

MonthDayYear
Date
What is the fundraising plan for the remaining $30,000 (between 1-3yrs):*

Single PaymentInstallments Over Three YearsCollective contributions from multiple donorsOther
Acknowledgment/Signature(s)

By signing, I confirm my commitment to support this nomination financially as outlined above. (please add a second page for additional signatures)
Nominators Signature*

Clear
Date*

MonthDayYear
Date
File Upload

Cancelof
Submit the completed form and supporting materials to: Elizabeth Plummer, Senior Director of Development, Marketing and Corporate Relations, at plummer@ota.org
Should be Empty:

Keystone Honor Nomination Form

Primary Nominator Information

OTA Keystone Honor Nominee Information