American Academy of Pediatric Dentistry - AAPD



-3143258572500American Academy of Pediatric DentistryNominations CommitteeCandidate Consideration FormOffice Sought: Western District TrusteeTerm Beginning: 2021 — 2024Candidate Contact InformationCandidate Name Click to enter.Office Address Click to enter.CityClick to enter.StateClick to enter.ZIPClick to enterOffice or work phone number Click to enter.Office or work fax number Click to enter.Preferred e-mail address Click to enter.Home phone number Click to enter.AAPD Activity and Experience(list in reverse chronological order, starting with most recent)Please do not add rowsCouncil/committee, position, or officeYear (s)Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.AAPD District or State Unit Organization Activity and Experiences(list in reverse chronological order, starting with most recent)Please do not add rowsOrganizationCouncil/committee, position, or office Year (s)Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Membership in AAPD District or State Unit OrganizationsDistrict Unit (Select from list): Choose district from list. State Unit(s): Click to enter.Pertinent Activity and Experience in Other Organizations(list in reverse chronological order starting with most recent)Please do not add rowsOrganizationPosition or office Year (s)Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Education and TrainingInstitution and LocationDateDegree/CertificateMajor/SpecialtyUndergraduateClick to enter.Click to enter.Click to enter.Click to enter.Dental school(s)Click to enter.Click to enter.Click to enter.Click to enter.ResidencyClick to enter.Click to enter.Click to enter.Click to enter.Graduate School (s)Click to enter.Click to enter.Click to enter.Click to enter.OtherClick to enter.Click to enter.Click to enter.Click to enter.Licensure and CredentialsLicensed to practice in: (list all states and applicable license number[s])Click here to enter state(s).Click here to enter license number(s).American Board of Pediatric Dentistry (indicate status):Yes/No Board Candidate (Enter year)Yes/No Diplomate (Enter year)Professional Activity(in reverse chronological order, indicating practice, teaching, research, federal/state service, and hospital activities. If engaged in multiple activities indicate percentage of time spent at each)Please do not add rows.ActivityYear (s)Institution or LocationPosition or TitleClick to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Click to enter.Honors, Publications and Presentations(Please list five most significant)DateSpecifics of Honor, Publication or PresentationClick to text.Click to enter.Click to text.Click to text.Click to text.Click to text.Click to text.Click to text.Click to text.Click to text.Attestation to Conditions of NominationEach item must be initialedIn submitting my name for nomination and signing this form, I understand and attest to the following:Enter initialsI agree to be considered by the Nominations Committee for elective office in the American Academy of Pediatric Dentistry. Enter initialsIf my name is placed in nomination and I am elected, I agree to serve the Academy in conformity with all provisions of the Constitution and Bylaws and the Administrative Policy and Procedure Manual.Enter initialsI am aware that no member of the Academy may profit monetarily by reason of membership or office, and I will remove myself from any activity, deliberation, or vote which presents a conflict of interest.Enter initialsI affirm that if elected, I will exercise the fiduciary duties of care, loyalty, and obedience.Enter initialsI affirm that the information submitted on this nomination form is true and accurate, and agree that should any statement be determined to be false or misrepresentative by the Nominations Committee, my nomination may be revoked. Enter initialsI affirm that my dental license (s) as indicated above is in good order and has not been revoked. Or, I offer the following explanation concerning a revoked or suspended license (attached page).Enter initialsI affirm that I have not been convicted of any crime, nor have I been the subject of any other judicial or administrative proceeding that would reflect negatively on the Academy should I be elected to this position.Enter initialsI will not engage any member of the Nominations Committee in any activities intended to influence the outcome of the nominations process including, but not limited to, campaigning, lobbying, or political polling, and I will not encourage, support, or endorse any person to do so on my behalf.Enter initialsI have attached (a) a one page essay explaining my interest in serving in this office and summarizing my leadership skills; (b) a background description suitable for publishing in Pediatric Dentistry Today; (c) three (3) letters of personal recommendation from active, life or retired members of the Academy; and (d) a photograph in electronic format suitable for publication in Pediatric Dentistry Today.Click to enter date.Signature ................
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