The 2015 awards of excellence



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The 2015
AWARDS
of EXCELLENCE

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Entry Form



1. Nominee Information


Name of Nominee: 







Mailing Address:







Phone:




Email:







Is the nominee a member of the Ohio Dental Association?







If yes, please list the nominee’s component dental society:







Nominee’s Occupation (If a dentist, please list type of practice):





2. Nominator Information


Name of Nominator (Individual ODA member or Component Dental Society): 







Mailing Address:







Phone:




Email:






3. Award Category

Please check the award category for this award entry.


 Distinguished Dentist Award

Achievement Award

 Marvin Fisk Humanitarian Award

 N. Wayne Hiatt Rising Star Award

 Access to Dental Care Program Award
4. Submission Materials

For the Distinguished Dentist Award, Achievement Award, Marvin Fisk Humanitarian Award and N. Wayne Hiatt Rising Star Award categories, a complete nomination packet includes the following:

 The nominee’s curriculum vitae (not to exceed 3 pages)

 A brief supporting essay (less than 1,500 words)

 A completed Awards of Excellence Entry Form
For the Access to Dental Care Program Award, a complete nomination packet includes the following:
 A description of the access to dental care program (1-2 types pages)

 A completed Awards of Excellence Entry Form


5. Deadline for Entries

All award entries must be received at the Ohio Dental Association office by April 20, 2015.


Send entries to:


  • Mail: Ohio Dental Association, Attn: David Owsiany, 1370 Dublin Road, Columbus, OH 43215

  • Fax: (614) 486-0381

  • Email: david@oda.org

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