DSA

LDA Distinguished Service Award Nomination Form

LDA Award nominations must be submitted by November 1. We suggest that you input your responses into a word document before completing the online form to eliminate the risk of losing your responses. If you have questions, contact the LDA office at (225) 926-1986. We can answer your questions or connect you with Dr. King Scott, Chairman of the DSA Committee.

Your Information

Your Name

Email Address

Phone Number

Nominee's Information

Nominee's Name

Date of Birth

Spouse's Name

Children's Name(s)

Address

Nominee's Phone Number

ADA #

How many years has the nominee been a member of the ADA/LDA?

Nominee's Local Component

General description of nominee’s dental practice.

Nominee’s service to the LDA and ADA (i.e. service projects, committees). Briefly describe the nature of the service, its value to the association and the year, chronologically beginning with the most recent.

Nominee’s service to the dental profession in general. Describe service to the profession other than ADA/LDA activities and the year(s). Include other dental organizations, projects (chronologically).

Community Service. Describe activities in the community and the year(s) of service such as volunteer work at community dental clinic, school and church activities (chronologically).

Other information you deem significant about the nominee.

On a Word Document or PDF, compose a two-paragraph statement of why you feel this person deserves this award from the LDA and organized dentistry. Please state your relationship to this person or why you are the person recommending the nominee for this award. Submit your statement below by clicking the "select" button.

LDA Distinguished Service Award Nomination Form

Your Information

Nominee's Information

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