This plaque is presented to an outgoing Section chair for their year(s) of service to the Academy.

It is typically presented by the newly installed incoming Section Chair to the outgoing Section Chair at the time of the installation as your first order of business.

The application must be submitted to the Central Office at least six weeks prior to the award presentation.

Outgoing Section Chair Information

Title

First Name *

Last Name *

Suffix

Degree

Street Address

Street Address Line 2

City

State / Province / Region

Postal / ZIP Code

Country

Section Chair Start Date *

Section Chair End Date *

Presentation Date: *

Submitted by

Select Your Region *

Select Your Section

Incoming Chairperson First Name *

Incoming Chairperson Last Name *

Phone Number *

Section Chair Email Address *

Address You Would Like the Plaque Shipped to: *

Address You Would Like the Plaque Shipped to: Line 2

City *

State / Province / Region *

Postal / ZIP Code *

Country *

Date Submitted: MM/DD/YYYY

Please Remember

Take photos of your Awardee as well as your event to send with your annual report to the International Office for publishing in Dental World and on the website.

Success! Your plaque order form has been sent.

There was an error trying to send this form. Please contact us at +1-240-658-8070 or centraloffice@fauchard.org.

Outgoing Section Chair Plaque Order Form

Outgoing Section Chair Information

Submitted by

Please Remember

Region 1 - Europe

Region 2 - Northeast USA

Region 3 - Southeast USA

Region 4 - Midwest USA

Region 5 - Western USA

Region 6 - Canada

Region 7 - Latin America

Region 8 - Australasia

Region 9 - Asia

Region 10 - Central USA

Region 11 - Africa

Autonomous Region