NCDHA Nomination Form

NCDHA NOMINATION FORM

Please complete this form in its entirety.

Email of person filling this form:

example@example.com

PART I. Nomination

I hereby officially declare myself or a colleague as a candidate for the following elective office of the North Carolina Dental Hygienists' Association.

Name of candidate:

Nomination is for office of:

President-Elect - is a term of one year andsucceeds to the office of President for one year and succeeds to the office of Immediate Past President for one year. President-Elect is a three yearcommitment and is a voting member of the NCDHA Executive Board.Vice President- is a term of one year and is avoting member of the NCDHA Executive Board. The Vice President shall have anyduties assigned by NCDHA’s President or Executive Board.Secretary - is a term of one year and is a voting member of the NCDHA Executive Board. The Secretary is responsible for maintaining accurate and sufficient documentation of all NCDHA Board meetings and the Annual House of Delegates meeting to meet legal requirements and authentic records. The secretary shall also have anyduties assigned by NCHDA’s President.Treasurer (not open for election for 2024)Treasurer-Elect - is a term of one year and succeeds to the office of Treasurer for one year. The Treasurer-Elect shall assist the Treasurer, the chief financial officer of NCDHA, and substitute for the Treasurer when required.ADHA Delegate/Alternate - is a term of two years and is required to attend the ADHA Annual Session. ADHA Delegate will also attend special ADHA meetings and keep NCDHA members informed of ADHA activitiesComponent Trustee - is as vital liaison between NCDHA and their respective local areas, championing the interests of their fellow hygienists, fostering collaboration, and nurturing leadership within their communities. Through their dedicated efforts, our trustees empower hygienists to take charge, lead initiatives, and make a lasting impact on the profession

For which NCDHA Component

PART II. Candidate's Record of Service & Qualifications

To be completed by candidate.

A. Membership:

Years as ADHA member:

Years as NCDHA member:

Years as Component member:

Component name, if applicable:

B. License(s):

State of License

Years licensed:

Other:

C. Offices Held:

ADHA Office (list position and year):

NCDHA Office (list position and year):

Local Component Office (list position and year):

D. Councils/Committees Served:

ADHA Councils/Committees (list position and year):

NCDHA Councils/Committees (list position and year):

Local Component Councils/Committees (list position and year):

E. Community Service:

List any community services outside of the professional association that bring additional qualifications for the office to the association. Provide the organization name, services rendered, and year(s).

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PART III. Candidate's Acceptance of the Nomination

To be completed by candidate.

I hereby accept my nomination for the office previously stated.*

I agree.I do not agree.