By completing this form you recognize the the important responsibility you are undertaking in serving as an officer/trustee of the American Dental Assistants Association.

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Disclosure Statement of Potential Conflicts of Interest

I hereby acknowledge that for each of the positions I hold related to The American Dental Assistants Association, I occupy a position of trust and that I am expected to act at all times in good faith and with loyalty to the Association. I have read the conflict of interest policy of the ADAA and support its intent. I declare that if any interest of mine or of any member or entity with whom or with which I have a significant relationship conflicts with my duties and responsibilities to the ADAA or could be perceived as conflicting with those duties and responsibilities, I shall voluntarily disclose that conflicting interest. In furtherance to the foregoing, the following questions have been answered to the best of my knowledge and belief:

*I pledge to the following:

• To establish as a high priority my attendance at all meetings of the board, committees and task forces on which I serve.
• To come prepared to contribute to the discussion of issues and business to be addressed at scheduled meetings, having read the agenda and all background support material relevant to the meeting.
• To work with and respect the opinions of my peers who serve on this board and to leave my personal prejudices out of all board discussion.
• To always act for the good of this association.
• To represent this association in a positive and supportive manner at all times and in all places.
• To observe the parliamentary procedures outlined in Roberts Rules of Order Newly Revised and display courteous conduct in all board, committees and task force meetings.
• To refrain from intruding on administrative issues that are the responsibility of staff management, except to monitor the results and prohibit methods not in congruity with board policy.
• To avoid conflicts of interest between my position as a board member and my personal life. If such conflict does arise, I will declare that conflict before the board and refrain from voting on matters in which I have a conflict.
• To support in a positive manner all actions taken by the Board of Trustees even when I am in a minority position on such actions.
•To agree to serve on at least one committee or task force (if asked to do so), attend all meetings and participate in the accomplishment of its objectives. If I chair a committee or task force I will:
•Call meetings as necessary (dictated by board policy and /or budgetary implications) or communicate with committee members until objectives are met.
• Ensure that the agenda and support materials are mailed to all members in advance of any meetings or teleconference calls.
• Conduct the meetings in an orderly, fair, open and efficient manner.
• Make committee and task force progress reports/minutes to the Board of Trustees at its scheduled meetings, using the adopted format.
• To participate in (a) any scheduled strategic planning (b) board development workshops, seminars and other educational events that enhance my skills as a board member.