2011-2012 MDA Humanitarian Award
Nomination Entry Form

Please complete and submit a separate form for each individual nominated.  Supporting documents must be included, example: newspaper clippings, articles, photos etc. or letters of recommendation.

Name of Nominee:
MDA District:

Please complete the following pertinent information:
Community Service :
 
Proactive Involvement in promotion good oral health to the public:
 

Voluntary involvement in donated dental services to needy people in both Mississippi and other areas of the country, including, but not limited to under served countries:

Nomination may be submitted by MDA members, associate members, employees of member dentists, or members of Dental Related Professions. 
Exp: Dental Lab, Mission First Clinic, DDS Coordinator or
UMC SOD / Alumni employees.

Name of person
submitting nomination:
MDA District:
Street Address:
City:
State:
Zip:
Phone:
Fax:
E-Mail:


Important Information:  Entries must be postmarked or sent via e-mail by the end of the day, February 1, 2012. Supporting materials can be scanned and sent electronically in Adobe .pdf  file format to office@msdental.org or may be mailed separately from this electronic submission form.  Please be sure to label mailed materials as Nomination Submission and mail to Mississippi Dental Association, CNADE, 439 B Katherine Dr., Flowood MS 39232.
Questions or Comments: