WDHA Martha Fales Award Application

The Association establishes an award of recognition of dental hygiene excellence to be known as The Martha Fales Award to recognize an outstanding dental hygienist for their contributions in furthering dental hygiene in Washington State. The award may be given annually with presentation of a commemorative plaque at the House of Delegates. 

 

Applications must be received at Central Office no later than 4 pm on the first Friday of August. The 2019 deadline is August 2nd.

 

Application Submitted By:

First Name
Last Name
Mailing Address
City
State
Zip
Contact Phone #
Email

Nominee Information

 

Nominee's First Name
Nominee's Last Name
Mailing Address
City
Zip
State
Nominee's Phone #
Nominee's Email
ADHA ID Number
Dental Hygiene License Number
RDH License State
Minimum 5 years Professional Membership in WDHA:
Minimum 10 years as a Registered Dental Hygienist:
Contributions in Furthering Dental Hygiene in Washington State: (i.e. clinical, education, legislation, public health, research, etc.)
Nominee's Curriculum Vitae

Please submit two letters of recommendation to support the nomination from individuals having direct knowledge of the nominee's accomplishments that include:

 

a) A specific description about the nominee’s accomplishments, or projects, in which the individual has been or is currently involved.
b) A description of how these efforts have, or will, contribute to the advancement of the profession of dental hygiene in Washington State.

 

Letters can be uploaded with online application, emailed to wsdha@comcast.net, or mailed to PO Box 389, Lynnwood, WA 98046. Letters must be postmarked by 8/2/19.

Upload your recommendation letter 1
Upload your recommendation letter 2
Are you attending this year's House of Delegates?
Please type your full name below for your signature.

Deadline for Application: August 2, 2019

Only online applications will be accepted.

 

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move