Humanitarian Award

LDA Humanitarian Award Nomination Form

LDA Award nominations must be submitted by November 1. It is suggested that you input your responses into a word document before completing the online nomination to eliminate the risk of losing your responses. If you have questions, contact the LDA office at (225) 926-1986. We can answer her questions or connect you with the DSA and Humanitarian Awards Committees Chair, Dr. King Scott.

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 of the dental profession in humanitarian efforts. Describe service to the profession and the year(s). Include other organizations, projects of service (chronologically).

Community Service. Describe activities in the community and the year(s) of service such as volunteer work including such activities as 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 Humanitarian Award Nomination Form

Your Information

Nominee's Information

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