Award: California Optometrist of the Year 2019

Submission Deadline: October 10, 2019

Nominating Society *

Nominee: *

Total number of years as a COA member: *

Total number of years in practice: *

Home address: *

Work address: *

Name of person submitting nomination: *

Phone number or email address of person submitting nomination: *

Describe the nominee’s public service outside of optometry to any or all of the following (30 points): country, state, or other political subdivision in any capacity; education; community; religious or service institutions; and charitable causes. *
(Maximum characters: 2000)
You have characters left.

Describe the nominee’s service to the visual welfare of the public in any or all of the following (20 points): sight-saving groups; legislative activities beneficial to the visual welfare of the public; participation in governmental health care programs; and participation in public service programs. *
(Maximum characters: 2000)
You have characters left.

Describe the nominee’s service to optometry (30 points): Contributions of personal time and effort on behalf of the profession’s advancement. *
(Maximum characters: 2000)
You have characters left.

Describe the nominee’s service to COA and affiliate organizations (20 points): service as an officer, committee chair or member, etc.; promotion of the association’s goals and programs; activity in support of association projects; and involvement in public information activities. *
(Maximum characters: 2000)
You have characters left.

Additional details about the nominee under 2,000 words, such as CV or biography: (optional)

Get New Image

Please enter the text from the image into the box below.
Note: the characters are case-sensitive.

Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.