Criteria: A Section Chairperson may present this award during an appropriate ceremony to an individual dentist for outstanding and dedicated service to the profession within that Section.

One award per year per Section is authorized.

The name and address of the nominee must be submitted to the Central Office at least six (six) weeks prior to the award presentation.

Honoree Information

Title

First Name *

Last Name *

Suffix

Degree *

Street Address

Street Address Line 2

Add A Photo of the Awardee

Choose File

State / Province / Region

Postal / ZIP Code

City

Country

Presentation Date: MM/DD/YYYY

Submitted by

Select Your Region *

Select Your Section

Chair Person First Name *

Chair Person Last Name *

Chair Phone Number

Chair Cell Phone Number

Chair Email Address *

Address you want the Plaque shipped to:

Street Address *

Street Address: Line 2

City *

State / Province / Region *

Postal / ZIP Code *

Country *

Date Submitted

Please Remember

to 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 Nomination has been sent.

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

Section Distinguished Dentist Award Nomination Form

Honoree Information

Submitted by

Address you want the Plaque shipped to:

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