Alumni Affiliate Nomination Form

Nominator Details
Please provide your contact information.
Name*
Title First Last
Phone Number*
Email*
Alumni Affiliate Candidate Details
Please provide contact information for the candidate.
Candidate Name*
Title First Last
Phone Number*
Email*
Candidate Profile*
Describe why you are nominating this candidate and how they meet the criteria (max. 250 words).
Positions held in the dental community*
(Professional, academic, etc.)
Key volunteer and community activities within the dental community*
Previous awards, recognition or notable achievements in the dental community
UBC connections (if known)
- Faculty
- Alumni
- Emeriti
- Other
Please describe
Please describe
If you know other colleagues who would support this nomination, please list them here.
Phone
This field is for validation purposes and should be left unchanged.

Nominator Details