• Nomination Form

    Nomination Form

    PDA member dentists or an administrator for a Tripartite Local may nominate a PDA member in good standing who has graduated from dental school within the last 10 years and made a significant contribution to the profession, their community, and/or organized dentistry. Please note that nominators who are related to the nominee are encouraged to solicit collaborating nominations from other dentists outside the family.
  • The candidate has made a significant contribution in at least one of the following areas (check all that apply and provide details for each of the checked areas):*

  • The Profession
    Describe how the candidate has made a significant contribution to the profession in the years after dental school. Does the candidate have any advanced degrees or training? Is the candidate involved in research or engaged in dental education? Does the candidate promote the profession to students?

  • Their Community
    Describe how the candidate has made a significant contribution to their community in the years after dental school. Provide details about activities such as, but not limited to, participation in local or statewide service projects, such as MOM-n-PA, Give Kids A Smile, Veteran's Access to Dental Care, volunteering at Community Dental Clinics, etc., or providing oral health education at health fairs or National Children Dental Health Month events.

  • Organized Dentistry
    Describe how the candidate has made a significant contribution to organized dentistry in the years after dental school. Describe the participant’s involvement in organized dentistry on the local, state and national levels.

  • Should be Empty: