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Washington State Dental Association

2016 CITIZEN of the Year
Nomination Form

Each year the WSDA requests nominations for the  Citizen of the Year Award from its members, looking for exemplary service to the community. 

The award exists to recognize a member dentist who has given outstanding service to a domestic and/or foreign community; to encourage others toward such activity; to reinforce values of volunteer service desirable in society; and to promote the image of dentistry.

The work should be based on civic activities not affiliated with organized dentistry, and can include any number of activities and organizations such as service organizations, schools, non-salaried government positions or church sponsored community activities. Volunteer work does not have to be dental related. The award is not intended for an individual who provides limited uncompensated services or provides such services to an underserved population in the course of business for which they are compensated.
    
    This year the award will be presented at the Citizen of the Year Award banquet held during the annual House of Delegates meeting on Friday, September 23 at Semiahmoo in Blaine, WA. We hope you'll join us in recognizing the good works of one of your own.

Dentists and their staff are now invited to nominate a WSDA member dentist for the 2016 award. The deadline for nominations is June 3. Forms and award guidelines are available from component society secretaries and executive directors, or the WSDA office.
Nominee's Name *
Nominee's Name
Nominee's Office Address
Nominee's Office Address
Special civic and charitable activities and/or accomplishments: (Please list with pertinent details and dates)
Please explain why you believe your nominee should receive this award.
Nominated By *
Nominated By
Phone *
Phone
Please check one · I am a: *