2021-2022 Leadership Institute Nomination Form

Nominate a Colleague for the 2021-2022 NOA Leadership Institute!

The Nebraska Optometric Association’s Leadership Institute was created to identify, educate, inspire, and empower a community of leaders to become engaged advocates for the profession. The Leadership Institute provides recently-licensed optometrists (licensed 10 years or less) in Nebraska, the opportunity to enhance their abilities to be successful practitioners and leaders in the profession and their community.

The form below is to nominate a colleague for the 2021-2022 NOA Leadership Institute. If you would like to apply for the Leadership Institute yourself, you can click here to go directly to the Application Form.

All doctors nominated by June 18 will receive additional information and the application form link for the upcoming Leadership Institute. Applications will then be reviewed by a Selection Committee and class participants will be notified in early August. The Leadership Institute is scheduled to start in September and conclude in Summer of 2022.

Nomination form deadline is June 18

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* 1. Nominee Information:

Name *

Practice

Address

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number

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* 2. Name of Doctor submitting nomination:

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* 3. Are you interested in sponsoring a scholarship for this nominee? ($375)

Yes

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* 4. If your nominee is not accepted into this year's Leadership Institute, are you interested in sponsoring another participant?

Yes