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Bio Data Form for District Trustee Candidates 2022-23

Before You Submit...

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

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

1. Copy of current dental hygiene license.

2. Using Addendum A (District Trustee Responsibilities to ADHA), Addendum B (Universal Skill Sets for ADHA Leadership), and Addendum C (Recommended Skill Sets for ADHA Trustees), please describe in no more than 2 pages the skills sets that you possess and your understanding of the position and legal responsibilities of District Trustee.

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.

4. 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