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Bio Data Form for Elected Office 2021-22

Before You Submit...

Candidates interested in applying for a position as an ADHA Elected Officer must submit a complete bio-data form and upload the required supplemental materials within it. Please submit your completed form with supplemental materials by Monday, February 1, 2021.

It is a good idea to make sure have all the supplemental information available for upload before you begin your bio-data form. The following supplemental materials are required within this form:

1. Copy of current dental hygiene license.

2. In the application process, the Nominating Committee requires two letters of recommendation. If the applicant is currently serving on the ADHA Board of Trustees, one letter recommendation is to be from a fellow ADHA BOT member. The additional letter should be from a constituent member with whom the applicant has served. If the applicant is not currently serving on the ADHA Board of Trustees, both letters should be from constituent members with whom the applicant has served. The letters of recommendation are to be from individuals familiar with your work and can comment meaningfully on your leadership and organizational skills sets, etc. The letters of recommendation CANNOT be from a current member of the Nominating Committee. These letters are to be uploaded directly into the submission form. Details on these letters can be found in Letters of Recommendation section of this submission form and in Addendum D.

3. In a brief paragraph, please describe your comfort level with and indicate a few recent examples of working in an electronic environment (e.g. email, conference calls, electronic meetings, ADHA website, social media, PowerPoint presentations, Microsoft Word and Excel).

4. A narrative statement up to three pages outlining why you are pursuing this opportunity at this time, including the leadership strengths and accomplishments you bring to the position.

5. Using the ADHA Position Description Document and Universal Skill Sets for ADHA Leadership, produce a document of no more than two pages describing the skills sets that you possess and your readiness and understanding of the responsibilities as a member of the board as well as the position that you seek.

6. In no more than three pages, please upload a brief resume which includes the following information in this order:
a. Education
b. Association Experience (Component, Constituent & National)
c. Professional Experience (Private Practice, Education, Managed Care)
d. Related Experience (Liaison Activities, Legislative Activities, Fundraising)
e. Unleashing Your Potential (UYP) and the year attended
f. Honors/Recognition.

7. Please review Addendums E & F (Conflict of Interest Policy and Disclosure Form & Rules of Conduct).

If you have any questions regarding the form, please contact Tyler Dempsay at