2026 Statement of Interest/ADA Delegate and Alternate Delegate

Statement of Interest

For Candidates for the Offices of ADA Delegate and Alternate Delegate
Instructions: Complete all of the fields on this form. There is no limit to the length of your answers. Upon clicking the SUBMIT button at the bottom, your responses and uploaded CV will go directly to Andrea McCormick, Executive Secretary. Remember the deadline is 5:00 p.m. on January 16, 2026.

Statement of Interest forms cannot be edited after submission; however, candidates may request that they be removed from consideration at any time following submission.
Name*
Email*
Bill@gmail.com
Preferred Phone*
Local Dental Society*
Why are you interested in this position?*
What relevant skills, qualifications, experience, etc. do you have, especially those that may not be obvious from reading your CV*
What else should those voting know about you?*
Upload CV (curriculum vitae)*

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