American Academy of Periodontology

Nominating Committee for the American Board of Periodontology

Candidate Nomination Form

Please submit this form no later than July 1st by

Scanning and e-mailing to:

OR

Via fax to Lynne A. Paul at

312-5787-3983

(Electronic submission are appreciated)

The following information is submitted for your consideration when you meet to select candidates for vacant positions on the American Board of Periodontology. I certify that the information presented is true and correct.

Name
AAP I.D. #
Address 1
Address 2
City / State / Zip
E-Mail

Education

Dental Degree / Year Granted
Granted By

Advanced Training in periodontics completed at:

Year Completed
Granted By

Research and/or training positions held (show academic rank, institution and years):

Year certified by the American Board of Periodontology:

Certification by other specialty board:

Name of Board
Year Certified

Does the nominee conduct a limited practice of periodontics? (please place X next appropriate answer)

Yes
No

If no, has the nominee conducted such a practice in the past? (please place X next to appropriate answer)

Yes
No

How many years has the nominee devoted to the practice of periodontics?

Full-Time Years
Part-Time Years

Percentage of time devoted to: (indicate percentage spent in each area)

Private Practice / Research / Teaching / Administration

Please attach additional pages to provide any other information you feel the committee should have for full consideration of your qualifications as a candidate for Director of the American Board of Periodontology.

For further information contact:Lynne A. Paul

Sr. Manager - Governance and Administration

800-282-4867 x3265

AAP Volunteer Interest (place an X next to all those that apply)

I’m interested in working with the local media in my area to inform consumers about periodontal disease
I’m interested in writing a “Best Practice” column for AAP’s magazine, Periospectives
My idea for a topic is:
I’m interested in speaking at a “Lunch and Learn” session at a local dental school
I’m interested in being an AAP State/Regional Liaison
I’m interested in being on an AAP committee
My experience and expertise is in:
Planning and Educational Programming
Dental Benefits/Reimbursement
Test Construction
Post-doctoral Education
Anesthesia
Practice Management and Marketing

AAP Committee Interest:

Positions available for 2014-2015 Academy year

(please click here for committee descriptions -

Administrative Committees

  • Finance Committee - up to three positions
  • Leadership Development and Qualifications Committee - six positions (six members eligible for reappointment)
  • State and Regional Assembly Coordinating Committee - three positions (two members eligible for reappointment)

Programmatic Committees

  • ADA Liaison Committee - one position (one member eligible for reappointment)
  • Anesthesia Committee - three positions (three members eligible for reappointment)
  • Continuing Education Oversight Committee - nine positions (nine members eligible for reappointment)
  • Education Committee - five positions (five members eligible for reappointment)
  • In-Service Examination Committee - seven positions (four members eligible for reappointment)
  • Patient Benefits and Advocacy Committee - three position (two member eligible for reappointment)
  • Practice Management and Marketing Committee - four positions (three members eligible for reappointment)
  • Research Submissions Committee - eight positions (eight members eligible for reappointment)

Note: There are typically more applications than open positions. The AAP may not be able to fulfill your first choice or place you on a committee for the year in which you are applying.

Instructions:

Volunteer applications are due April 30th

Note: The deadline for receiving applications for the In-Service Examination Committee is February 28th. This appointment is made at the May Board of Trustees meeting.

  1. Limit choices to no more than three (3) committees.
  2. List the committees in order of preference.
  3. For each committee:
  4. Please indicate why you want to serve.
  5. Please list any relevant experience in professional or community organizations.
  6. Please indicate any special training or abilities you have which would help you to contribute to the mission of that committee.

You will receive a confirmation when your application is received. The open positions are effective 9/22/14 - 11/15/15. The evaluation process may take several months after the applications are received.

Choice #1

Limit your choices to the committees on Page 2

Please explain the reason(s) that you would like to serve on this committee, relevant experience, related training or abilities.

Choice #2

Limit your choices to the committees on Page 2

Please explain the reason(s) that you would like to serve on this committee, relevant experience, related training or abilities.

Choice #3

Limit your choices to the committees on Page 2

Please explain the reason(s) that you would like to serve on this committee, relevant experience, related training or abilities.

References

Please provide the names and contact information of at least two references who you have worked with in a volunteer or leadership capacity:

Reference #1

Name
E-Mail Address
Phone Number

Reference #12

Name
E-Mail Address
Phone Number

Curriculum Vitae

See example - cv may not exceed three (3) pages. If you submit a cv that exceeds maximum length, only the first three pages will be considered.

SAMPLE CV

Harry J. Olsen, DDS

1234 Any Street, Suite 230

318-444-2345 (cell)

EDUCATION

1998-2002University of ______School of Dentistry

DentalAny City, USA 22222

Degree: D.D.S., June 2002

1994-1998University of Indiana

CollegeHammond, Indiana

Degree: B.S. Bacteriology, May 1998

EMPLOYMENT EXPERIENCE

1988-1994Dentech Dental Laboratory

999 Walnut Street

Pasadena, California

Duties: Manager, Prosthetic Lab

HONORS AND AWARDS

1998John Sullivan Scholarship (3.75 GPA)

2001Omicron Kappa Upsilon

1991-2001Dean’s List (all semesters)

University of ______School of Dentistry

OTHER EDUCATON OF NOTE

5/2000-11/2000Alameda County Hospital

Hospital Dentistry Internship

PRINCIPLE PROFESSIONAL INTEREST

2002-presentSolo General Practice

Any City, California

RECENT PUBLICATIONSList Most Recent Publications Here

MEMBERSHIPS IN PROFESSIONAL ORGANIZATIONS

2002-presentAmerican Dental Association

California Dental Association

______Dental Society

2003-presentSouthwest Esthetic Study Club

San Clemente, California

POSITIONS HELD IN PROFESSIONAL ORGANIZATIONS

2004Member, CE Program Committee

______Dental Society

PROFESSIONAL REFERENCESG.V. Black, Professor of Restorative Dentistry

Chicago, Illinois

318-333-2222

ANY ADDITIONAL EXPERIENCE SIMILAR TO THAT REQUIRED FOR THE POSITION(S) APPLIED FOR?

Last Updated - June, 2014