FACULTY MEMBERSHIP AWARD APPLICATION

FACULTY MEMBERSHIP AWARD APPLICATION
The Association annually recognizes accredited Washington State dental hygiene programs that have 100% membership in ADHA/WDHA by all dental hygiene faculty (part-time and full-time), by presentation of an engraved plaque or year marker at House of Delegates and acknowledgment in Association publications. Recognition will be made by presentation of an engraved perpetual plaque (or credential for the current year for schools having already received their plaque) at House of Delegates.
Date Submitted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Submitted By
Address
Cell
Email
example@example.com
ADHA/WDHA Membership Number
Member since
WA License Number
How long have you practiced dental hygiene
Dental Hygiene School
TitlePosition at Dental Hygiene School
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Washington Dental Hygienists' Association P.O. Box 53394, Bellevue, WA 98015 or E-mail to: info@wsdha.com

Date Received: Membership Chair review/signature: Date Reviewed:
Should be Empty: