OPTA Awards - Nomination Form

Oregon Physical Therapy Association - 503-262-9247

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Nomination Form
Prior to February 15, 2008. Nominations received after this date cannot be considered.

Award you are nominating for:

Name of Nominee:

Address:

City, State, Zip:

Home Phone:

Work Phone:

E-mail:

OPTA Member:

Number of Years:
(If you do not have this information, please call APTA 1-800-999-2782 to obtain it.)

Please provide a support statement which details this individual's contribution(s) to the physical therapy profession and/or association which you feel merit(s) recognition through the award for which you have nominated this candidate using the guidelines specified above. Please be sure to provide information which meets the specific criteria for the award and include details about educational background, employment, APTA/OPTA activities and other activities.

Member Making Nomination:

Address:

City, State, Zip:

Phone:

E-mail: