Florida Delegation Nomination - 2020
Nomination forms must be completed to be considered for a position on the Florida Delegation. For inclusion in the 2020 June House of Delegates agenda forms must be submitted by May 4, 2020. Forms received after that date will be emailed as a supplemental item.
Name
*
First Name
Last Name
Email
*
example@example.com
ADA Number/First Year of Membership
*
ADA Number
First Year of Membership
Member of Delegation Since:
*
Component/Affiliate
*
Component
Affiliate
Dental School /Graduation Year
*
Dental School
Graduation Date
Practice or Specialty
*
Seeking Appointment as:
*
At-Large Alternate Delegate
Leadership Experience
*
0/130
Photo
*
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Professional Heashot Preferred; 300 dpi
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