American Academy of Periodontology
AAP Volunteer Registry Application Form
Please submit this form by saving the document and e-mailing it as an attachment to
eileen@perio.org. Questions - contact Eileen Loranger(800-282-4867.
Date
Name
Address 1
Address 2
City
State
Zip
E-Mail
Education
Degree
Year Granted
Granted By
Degree
Year Granted
Granted By
Degree
Year Granted
Granted By
Degree
Year Granted
Granted By
Board Certified (indicate yes or no)
Professional Concentration (indicate percentage spent in each area)
Private
Practice
Research
Last Updated – January 2016
Teaching
Administration
Volunteer Experience
Describe
Year
State/Regional Periodontal
Society Committee or other
volunteer capacity
State Dental Society Committee
or other volunteer capacity
State Dental Board Experience
AAP State and Regional
Assembly Experience
AAP Volunteer Experience
AAP Foundation Experience
Other volunteer experience
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:
Being an AAP State/Regional Liaison
Being on an AAP committee
Having my name provided to state/regional periodontal societies for volunteering
Participating in AAP members surveys
Participating in an AAP panel (feedback on AAP issues/ideas)
Speaking at Lunch N Learn at local dental school
Volunteering for American Academy of Periodontology Foundation (AAPF)
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 – January 2016
AAP Committee Interest:
Positions available for 2016-2017 Academy year - please note that there are always members eligible for
reappointment so the numbers of vacancies may be reduced.
(please click here for committee descriptions - http://www.perio.org/nea/appoints.html)
Administrative Committees
 State and Regional Assembly Coordinating Committee - three positions
 Volunteer Qualifications and Awards Committee - three positions
Programmatic Committees
 ADA Liaison Committee - two positions
 Anesthesia Committee - four positions
 Continuing Education Oversight Committee - nine positions
 In-Service Examination Committee - six positions
 Membership Advisory Committee - two positions
 Patient Benefits and Advocacy Committee - three position
 Research Submissions Committee - eight positions
 Scientific Oversight Committee - four positions
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 – January 2016
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:
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 9/12/16.
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 – January 2016
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 – January 2016
SAMPLE CV
Harry J. Olsen, DDS
1234 Any Street, Suite 230
318-444-2345 (cell)
holsen@yahoo.com
EDUCATION
1998-2002
Dental
University of __________ School of Dentistry
Any City, USA 22222
Degree: D.D.S., June 2002
1994-1998
College
University of Indiana
Hammond, Indiana
Degree: B.S. Bacteriology, May 1998
EMPLOYMENT EXPERIENCE
1988-1994
HONORS AND AWARDS
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
PROFESSIONAL REFERENCES
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
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 – January 2016