AFA/OTA Community Surgeon Achievement Award Nomination Application

Please complete the application to apply or nominate a colleague.  
Then, please email the nominees CV to Darlene Meyer: meyer@ota.org.
Deadline:  March 15, 2018

Questions? Please call 847-430-5133.

Please fill in the following fields:

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* 1. Please fill in the following fields:

Who are you nominating?

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* 2. Who are you nominating?

I (or my nominee) meet the following eligibility requirements:

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* 3. I (or my nominee) meet the following eligibility requirements:

Please describe how you/your nominee has demonstrated outstanding community orthopaedic contributions in the communities he/she serves including describing the community itself:  location, demographics, challenges met to serve (limit 250 words).

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* 4. Please describe how you/your nominee has demonstrated outstanding community orthopaedic contributions in the communities he/she serves including describing the community itself:  location, demographics, challenges met to serve (limit 250 words).

Please describe how you/your nominee has demonstrated an ongoing commitment to the advancement of orthopaedic research and education at the community level (limit 250 words).

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* 5. Please describe how you/your nominee has demonstrated an ongoing commitment to the advancement of orthopaedic research and education at the community level (limit 250 words).

Please describe your or your nominee's personal qualities of integrity, compassion and leadership in orthopaedic trauma.

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* 6. Please describe your or your nominee's personal qualities of integrity, compassion and leadership in orthopaedic trauma.

Please email the nominees CV to meyer@ota.org. Questions?  Please call Darlene Meyer at 847-430-5133.

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* 7. Please email the nominees CV to meyer@ota.org. Questions?  Please call Darlene Meyer at 847-430-5133.

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