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AWARDS NOMINATION FORM rev 10/2011 (Loyal Assistant Award)

AMERICAN DENTAL ASSISTANTS ASSOCIATION - AWARDS NOMINATION FORM rev 10/2011 - LOYAL ASSISTANT AWARD

A separate form MUST be submitted for EACH nomination - CONTACT ADAA CENTRAL OFFICE, please allow 2 business days for confirmation, if confirmation is not received, contact our office - do not resubmit form.

It is your responsibility to contact central office if a confirmation of receipt email is not received. This nomination form is NOT used with entries for the Student Achievement Award or Mosley Distinguished Service Award.

Letters of Recommendation - EMAIL SEPARATELY to nrod@adaa1.com (Subject: Awards Letter of Recommendation), you will be notified when received.

PLEASE NOTE: Notarizations, letters of recommendation, reference and other documents must be sent as a separate attachment to nrod@adaa1.com. When submitting separate attachment, include name of Award, name of Award nominee and submitter information.

When sending forms:

Do not submit this form more than once for the same recipient. If you have a question about your entry, contact Nancy Rodriguez
You will receive a confirmation once it has been accepted/returned for further information
Please use proper grammar, ADAA will not change the format of the form
Do not use ALL CAPS, do not use all lower case
REMEMBER to submit additional documentation separately

DO NOT USE THE RETURN BUTTON UNTIL YOU ARE FINISHED, THIS WILL SUBMIT YOUR FORM, COMPLETE OR INCOMPLETE

Award Nomination for:

Loyal Assistant Award

First/Last Name:

Address:

Address 1

Address 2

City

State

Zip

Date of Birth:

ADAA Member Since:

Nominated by:

Phone #:

Nominee's Current Employer:

Employer's Address:

Address 1

Address 2

City

State

Zip

Employer's Phone #:

Fax #:

Positions/Years Employed:

E-Mail:

Education Post High School (list on separate lines)

List credentials and how long held (list on separate lines)

Offices Held/Organization:

Submitted by:

Date:

Before clicking submit:

Do not submit this form more than once for the same recipient. If you have a question about your nominee, contact Nancy Rodriguez
Verify use of proper grammar, ADAA will not change the format of the form
Do not use ALL CAPS, do not use all lower case
REMEMBER to submit additional documentation separately
You will receive a confirmation that your submission has been received