Candidate Application Instruction Sheet
Please read and follow these instructions carefully. If you need assistance, contact Kristin Dee at SCDA at or by phone at 312.527.6764.
Please type all responses. Materials should be emailed back as word documents. If necessary, documents can be faxed to 312.673.6663.
The application documents included within this packet include:
1. Nomination Application (pg. 2-4)
2. Reference Questionnaire (pg. 5)
3. Conflict of Interest Disclosure Form (pg. 6)
Enter your own personal information on each document. For questions that have a maximum word limit, be careful not to exceed that limit. Do not use any formatting such as bullet points, bold, underline, special fonts, tabs, etc.
When you enter your SCDA Association Activities on the Nomination Application, list your activities in reverse chronological order, starting with your most recent activity. In the Dates column, enter the year you began and the year you completed the activity (e.g., 1993-1994).
The completed application will include:
Your completed Nomination Application & Questionnaire
Completed Reference List
Signed Conflict of Interest Form
Copy of Resume or Curriculum Vitae
Head shot photo (.jpg file)
SCDA
330 N. Wabash Avenue, Chicago, IL 60611
Attn: Kristin Dee
FAX: (312) 673-6663 Email:
It is preferred that you email completed copies in their original Microsoft Word format.
IMPORTANT: Applications postmarked after October 9, 2015 will not be considered.
Board of Directors Nomination Application
Position for which you are applying: □ Vice President □ Director-at-Large
Contact Information
Name:
Address:
Email Address:
Page 2 of 6
Home Telephone:
Business Telephone:
Professional Information
Years in dental profession:
Years in treating patients with special needs:
List area(s) of expertise:
Volunteer Information
List current positions held on any volunteer Board of Directors:
List any positions held on any volunteer Board of Directors within the last 5 years:
Number of years in SCDA:
Please check which Council(s) you are actively associated in:
□ Council of Geriatric Dentistry
□ Council of Hospital Dentistry
□ Council of Dentistry for People with Disabilities
List your participation in any SCDA activities/committees (including former Component Boards)
Dates of Activity Position
Current Personal or Professional Activities (within the last 5 years)
Dates of Activity Position Organization Name
Publications and Educational Presentations (within the last 5 years)
Date Forum (article, presentation, etc.) Title
Page 2 of 6
Please answer the following questions. Use of specific examples to illustrate your answers is encouraged. If you are placed on the ballot, a brief summary of your responses to questions 1-5 will be provided to the membership. If you have applied for a Board position in the past, please consider writing new responses to indicate how your thinking may have changed since your last application.
1. What is your vision for the SCDA and the special care dentistry profession?
2. What is motivating you to seek a position on the SCDA Board of Directors at this time?
3. In your review of the current strategic plan, describe how your skills and experiences might contribute to the Board’s implementation of the plan. In crafting your answer, you can address specific initiatives or address the plan more broadly as a whole.
4. Please highlight any exceptional skills or experiences you have, such as writing, communication, leadership, financial, or other skills, that may not be evident in your CV.
5. The SCDA Board of Directors values diversity of all kinds, including diversity in skill, specialty, experience, culture, ethnicity and gender. What diverse characteristics will you bring to the SCDA Board of Directors?
Your responses to questions 6-9 will only be used by the Nominating Committee.
6. Think of a time when you were in a leadership role (either volunteer or professional). Explain a challenging situation and what you learned or gained from the experience.
7. Describe a difficult decision you made while in a leadership role. How did this affect you personally?
8. How would an SCDA Board position differ from other leadership roles you have held? How would it be similar?
9. FOR REPEAT CANDIDATES ONLY: If you have applied for a Board position in the past, please indicate why you believe you are a better candidate now?
REFERENCE LIST
Please provide at least two professional references that may be contacted by the Nominating Committee if additional information is needed.
1. Name of Reference:
Reference Contact Phone:
Reference Contact E-mail:
2. Name of Reference:
Reference Contact Phone:
Reference Contact E-mail:
3. Name of Reference:
Reference Contact Phone:
Reference Contact E-mail:
POLICY ON CONFLICT OF INTEREST
The Officers, Directors, Committee members and staff members of the SCDA must avoid conflicts between their duties to the Association and their other duties and interests (including duties to other entities and their own personal interest, financial or otherwise). SCDA Leaders are prohibited from having relationships which present any such conflicts of interest during their terms of service.
Conflict Affiliations include but are not limited to:
(i) having a material ownership interest, direct or indirect (e.g. through stock ownership or a partnership interest) in any entity which the SCDA Leader knows or should know is a vendor of goods or services to the SCDA, or
(ii) serving in a management or key operational position (e.g. as an officer or director) for any entity which the SCDA Leader knows or should know is a vendor of goods or services to SCDA.
Each SCDA Leader is under an obligation to the Association to disclose any and all actual or potential Conflict Affiliations. Accordingly, each SCDA Leader shall execute annually and upon the occurrence of any actual or potential Conflict Affiliation the following Disclosure Statement.
I have read and understand the above Conflict of Interest Policy of the SCDA. I agree to abide by this Policy, and have listed below all of my actual of potential Conflict Affiliations.
______I hereby disclose the following actual or potential conflict affiliations:
______
______
______
______
______
______I have NO actual or potential conflict affiliations.
Signature:
Print name:
Date:
Page 6 of 6