NCDHA Bio-Data Form

NCDHA BIO DATA FORM

Email of person filling this form:

example@example.com

Name

First NameLast Name

ADHA Membership #:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone:

Home Phone:

Work Phone:

Preferred email:

License Number:

State:

Status:

License Number:

State:

Status:

License Number:

State:

Status:

Current Professional Position:

Elective office you are seeking:

For Which NCDHA Component?

Appointments to NCDHA Action Committees:

Please attach a brief resume (typed, one page) including the following information in this order:

I. Education
II. Association Experience (component, constituent, and national)
III. Professional Experience (private practice, education, public health, etc.)
IV. Related Experience (liaison activities, legislative activities, foundation/fundraising, etc.)
V. Awards/Recognition

The form bio-data and resume will be forwarded to the President for consideration. A cover letter may be attached, but will not be attached to the information that is forwarded.

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COMMITMENT: I understand acceptance of appointment to any NCDHA position indicates a substantial personal commitment for at least one year, as well as a willingness to represent the NCDHA mission, goals, and policies. I assume responsibility for updating NCDHA of any changes in the above information. I understand that I will be required to sign a Conflict of Interest form and a Rules of Conduct form.