OPTA Awards - Nomination Form

Oregon Physical Therapy Association - 503-262-9247

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Nomination Form
The deadline has been extended to March 18, 2011.

Required fields are marked with an *

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: *

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147 SE 102nd Avenue, Portland, Oregon 97206
Phone: 503.262.9247 * Toll-free: 877.452.4919
Fax: 503.253.9172
Email: info@opta.org

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