Dental Committee Member Application
Full Name
*
Title
Full name
Email
*
example@example.com
Phone number
Address
Full Signature and titles
Are you a licensed vet?
Yes
No
If not, what is your job title?
Nurse
Technician
Researcher
Student
What university/college did you graduate from?
Are you a member of a WSAVA Association
*
What WSAVA Member Association are you a member of? If you are not a member, fill in 'none'
Member of other veterinary associations?
Current employment
please list all paid positions that you hold for any organisation, company or other
Volunteer position
please list all volunteer positions that you hold, such as board positions, committee positions for any organisation,company or other
Any other qualifications?
Do you believe there is any conflict of interest in relation to your employment&/or other positions and the WSAVA position for which you are applying?
Curriculum Vitae
*
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Please attach your CV in English
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Letter of good standing from a WSAVA Member Association
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All nominees for membership of any WSAVA committee/group are required to provide a letter of Good Standing from the WSAVA member organization of which they are a member. This requirement does not apply to nominees who are not members of a WSAVA organization (e.g. non-veterinarians) whose expertise may be necessary for specialist committees/groups. A person of Good Standing is defined as someone who has complied with all explicit obligations of the association and who is not subject to any form of sanction, suspension or disciplinary censure. This letter is not a recommendation from the association that the nominee is the best person for the position. WSAVA committee positions are not chosen by member organizations - the Committee Chair ultimately decides on the best candidate for the position and the choice is ratified by the Membership and Nomination Committee and the Executive Board. This letter indicates only that the WSAVA member association has no objection to the nomination.
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Letter of Intent
*
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Letter of Intent addressing the duties outlined in the job description
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Conflict of Interest and Disclosure of Certain Interests
If any of the below questions are not relevant, please state not applicable in the answer fields.
Please describe below any relationships, positions, or circumstances in which you are involved that you believe could contribute to a Conflict of Interest, whether actual, potential, or could be perceived.
Are you employed by, a director for, or a member of an advisory board or special interest group, for any WSAVA Industry Partner (sponsor).
Are you assisting in the design of clinical studies concerning the use of products manufactured by a WSAVA Industry Partner (sponsor)?
Do you hold investments in an organisation that is a WSAVA Industry Partner (sponsor)?
By select yes below, I hereby certify that the information given above is true and complete to the best of my knowledge, and that I have read and agree to abide by the WSAVA Conflict of Interest Policy.
Yes
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