Nominating Committee for the American Board of Periodontology
Candidate Nomination Form
Please submit this form no later than July 1 st by
Scanning and e-mailing to: lynne@perio.org
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
E-Mail
Education
Dental Degree Year Granted
Granted By
Advanced Training in periodontics completed at:
Year Completed
Zip
Granted By
Research and/or training positions held (show academic rank, institution and years):
Year certified by the American Board of Periodontology:
Last Updated - June, 2014

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 lynne@perio.org
800-282-4867 x3265
Last Updated - June, 2014

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
Last Updated - June, 2014

AAP Committee Interest:
Positions available for 2014-2015 Academy year
(please click here for committee descriptions - http://www.perio.org/nea/appoints.html
)
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.
Last Updated - June, 2014

Instructions:
Volunteer applications are due April 30 th
Note: The deadline for receiving applications for the In-Service Examination Committee is February 28 th . 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: a.
Please indicate why you want to serve. b.
Please list any relevant experience in professional or community organizations. c.
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.
Last Updated - June, 2014

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.
Last Updated - June, 2014

1234 Any Street, Suite 230
318-444-2345 (cell) holsen@yahoo.com
EDUCATION
1998-2002
Dental
1994-1998
College
EMPLOYMENT EXPERIENCE
HONORS AND AWARDS
1988-1994
1998
2001
1991-2001
OTHER EDUCATON OF NOTE
5/2000-11/2000
PRINCIPLE PROFESSIONAL INTEREST
2002-present
RECENT PUBLICATIONS
MEMBERSHIPS IN PROFESSIONAL ORGANIZATIONS
2002-present
2003-present
POSITIONS HELD IN PROFESSIONAL ORGANIZATIONS
2004
University of __________ School of Dentistry
Any City, USA 22222
Degree: D.D.S., June 2002
University of Indiana
Hammond, Indiana
Degree: B.S. Bacteriology, May 1998
Dentech Dental Laboratory
999 Walnut Street
Pasadena, California
Duties: Manager, Prosthetic Lab
John Sullivan Scholarship (3.75 GPA)
Omicron Kappa Upsilon
Dean’s List (all semesters)
University of ___________ School of Dentistry
Alameda County Hospital
Hospital Dentistry Internship
Solo General Practice
Any City, California
List Most Recent Publications Here
American Dental Association
California Dental Association
____________________ Dental Society
Southwest Esthetic Study Club
San Clemente, California
Member, CE Program Committee
___________________ Dental Society
PROFESSIONAL REFERENCES G.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