OHIO ATHLETIC TRAINERS’ ASSOCIATION
HALL OF FAME
CANDIDATE BIOGRAPHY SHEET
(Award Biographies will be produced from this information )

Name (Last, First): ,

Email Address:
Confirm Email:

BOC certification # (9 digits, NOT the Membership number )
Ohio License # (ex. AT-XXXXXX)
O.A.T.A. Membership Status: Select: Class 01: Active Class 03: Retired

Date Submitted (mm/dd/yyyy):

Home Address:
Street:
City:
State Zip Code
Home Phone (xxx-xxx-xxxx):

Primary Place of Employment
Schools covered (if necessary):

Office address:
Street:
City:
State Zip Code

Office phone (xxx-xxx-xxxx):

Curriculum Vitae (cut & paste):

Attachment of Nominee's Curriculum Vitae or Resume:

List Names & Titles of persons writing letters of support:
1.

2.

3.

4. (if necessary)

5. (if necessary)