UCLA Dentistry Alumni of the Year Award Nomination Form
Nominate an inspiring alumnus who demonstrates exceptional dedication, service, and contributions in roles related to the UCLA School of Dentistry, the community, and the dental profession.

All submissions are considered and reviewed by the UCLA Dentistry Awards Selection Committee. Award recipient will be announced in May 2021.

The deadline to submit a nomination is Feb. 1, 2021. For questions, contact alumni@dentistry.ucla.edu or visit https://www.dentistry.ucla.edu/alumni/alumni-awards.
Your Name *
Your Email *
Your Affiliation to Nominee (Colleague, Friend, Family, etc.)
Next
Never submit passwords through Google Forms.
This form was created inside of Google Apps for UCLA. Report Abuse