Council and Subcommittee Application Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Contact Information Name *FirstMiddleLastSuffixMember IDAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCountry *Email *Cell Phone *Work Phone *Qualifications of Candidate Please list any previous experience including committee/officer experience at local, state, and national level. *List any degrees or credentials that you currently hold. *Work Experience (check all that apply): *Business AssistantChairsideEducatorLab TechOffice ManagerOffice SalesOtherOtherTotal Years Experience: *If you have specific councils or subcommittees of interest, please indicate and describe specific experiences or activities that you believe enhance your qualifications to serve on a national council or subcommittee. *Council Volunteer Agreement *YES, I will accept the President’s volunteer appointment to a council. I understand that because many members volunteer each year and are not accommodated due to the limited number of assignments available, it is imperative that those who are selected commit their time, talent, and cooperation to the project. Therefore, in accepting my appointment, I promise to be responsible to ADAA and my colleagues as follows: I shall be thoroughly knowledgeable of the ADAA Bylaws, Manual of Procedures, Policies, and Strategic Plan, specifically as they pertain to my Council and its assignment(s). I shall have computer and e-mail access in order to read, review, and respond to all e-mail correspondence on a regular basis. I shall attend and participate in all meetings and conference calls, and e-mails realizing that failure to do so could result in my being replaced on the Council. I shall communicate knowledge actively and regularly, bringing pertinent information and business to the attention of the Council. I shall accept responsibility for decisions and support the decisions of the Council, regardless of personal opinions. I shall complete assignments that I volunteer to do for my Council within the established deadlines. I shall be subject to evaluation at year-end to determine future Council participation. DropdownYesNoChoose OneBy entering your name below, you accept all of the above. *Submit
