AFA/OTA Community Surgeon Achievement Award

Please complete the application to apply or nominate a colleague.

Then, please email the nominees CV to Darlene Meyer: meyer@ota.org.

Deadline: April 10, 2017

Questions? Please call 847-430-5133.

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* 1. Please fill in the following fields:

Name:

Email:

Phone number:

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* 2. Who are you nominating?

self

colleague

Colleague's Name:

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

I am an active, Board certified, community orthopaedic trauma surgeon.

I am an OTA Member.

I agree to attend the 2017 OTA Annual Meeting in Vancouver, BC. I understand that I may be asked to give a short presentation at this meeting.

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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).

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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).

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

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