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:

President-Elect - is a term of one year and succeeds 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 year commitment 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 any duties 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 any duties assigned by NCHDA’s President.Treasurer (not open for election for 2024)Treasurer-Elect - isa term of one year and succeeds to the office of Treasurer for one year. TheTreasurer-Elect shall assist the Treasurer, the chief financial officer ofNCDHA, 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 theinterests of their fellow hygienists, fostering collaboration, and nurturingleadership within their communities. Through their dedicated efforts, ourtrustees empower hygienists to take charge, lead initiatives, and make alasting impact on the profession
For Which NCDHA Component?
Appointments to NCDHA Action Committees:

IOH CommitteeCommunications CommitteeNCDHA Bylaws CommitteeGovernmental AffairsMembershipFundraisingNC-CDPNCMOMIOHNC-DHL
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.*

I agree.I do not agree.
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