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.Format: (000) 000-0000.
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.
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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):

Other
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
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