Leo Doerfler - Award Nomination Form

Note:These fields are REQUIRED
Deadline for all submissions is July 31, 2017

For more information regarding the Leo Doerfler award, click here.


Nominee Information:
Full Name:
Street Address
City:
State:
Zip:
Telephone:
E-mail Address:
   
Degree or Designation:
ADA Member ID:
Join Date:
Number of Years in Private Practice:
Number of Years as a Practice Owner:
Practice Specialty:

Nominator Information:
Full Name:
Relationship to Nominee:
# of years that you've know the Nominee
Telephone:
E-mail Address:

Required Essay:

The Leo Doerfler Award was created in 2003 to recognize an audiologist who has demonstrated outstanding clinical services in the community throughout his/her career. The award honors ADA's first President, Dr. Leo Doerfler, a practitioner who is remembered for pioneering the private practice model. Eligibility for the Doerfler Award is open to ADA members who are private practitioners.

Please describe (in 500 words or fewer) your reasons for nominating this individual to receive the Leo Doerfler Award. Please include a description of this candidate’s entrepreneurial spirit and outstanding clinical service, as well as relevant volunteer roles in the profession and the community.


Please enter the verification code below and click submit:
Please note that all required fields must be entered in order to submit your application. You may need to scroll through the form to see which required fields you've missed.