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 Vice President Secretary Treasurer Treasurer-Elect ADHA Delegate/Alternate Component Trustee

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.