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Bio-Data Form for Elected Office 2022-23

Before You Submit...

Candidates interested in applying for a position as an ADHA Elected Officer must submit a complete bio-data form and upload the required supplemental materials within it. Please submit your completed form with supplemental materials by Monday, February 7, 2022.

It is a good idea to make sure have all the supplemental information available for upload before you begin your bio-data form. The following supplemental materials are required within this form:

1. Copy of current dental hygiene license.

2. In the application process, the Nominating Committee requires two reference letters from individuals familiar with your work who can comment meaningfully on your leadership and organizational skills sets, etc. The letters of recommendation CANNOT be from a current member of the Nominating Committee or Leadership Development Committee. These letters should be submitted confidentially by the author to the chair of the Nominating Committee at .

3. Please provide a professional summary limited to 200 words including information on the following:
a. Education
b. Association Experience (Component, Constituent & National)
c. Professional Experience (Private Practice, Education, Managed Care)
d. Related Experience (Liaison Activities, Legislative Activities, Fundraising)
e. Professional Honors/Recognition.

7. Please review Addendums E & F (Conflict of Interest Policy and Disclosure Form & Rules of Conduct).

If you have any questions regarding the form, please contact Kathy Pujol at