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Bio Data Form for District Trustee Candidates 2021-22

Before You Submit...

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

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

1. Copy of current dental hygiene license.

2. Using Addendum A (District Trustee Responsibilities to ADHA), Addendum B (Universal Skill Sets for ADHA Leadership), and Addendum C (Recommended Skill Sets for ADHA Trustees), please describe in no more than 2 pages the skills sets that you possess and your understanding of the position and legal responsibilities of District Trustee.

3. One letter of recommendation from a fellow ADHA or Constituent board member that is to be uploaded directly into this submission form. The letter of recommendation CANNOT be from a current member of the Nominating Committee. Details on this letter can be found in Addendum D. You will also be asked to provide the contact information for the person writing the letter of recommendation.

4. 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.

5. 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 Kathy Pujol at