The Stephenson Honorary Fellow Award
Nomination Form
Name of nominee (first and last name):
Contact information of nominee:
Postal address:
Email address:
Phone number (if known):
Name of nominator (first and last name):
Email address:
Country:
Signature_____________________________________________ (electronic signature is acceptable)
Date __________________________________________________
All applications must be received by the IOA Secretary, Katherine Fray
by February 1st 2016. Send to secretary@internationalorthoptics.org