NJ Dental Foundation Board of Directors Nomination Form

Thank you for your interest in serving on the NJ Dental Foundation Board of Directors. Please provide the following information to help us understand your background, experience, and motivation for joining the board.

Personal Information

First Name

Last Name

Email Address

Phone Number

Mailing Address

City

State

Zip Code

Current Position/Title

Employer/Organization

Dental License Number (if applicable)

Gender

Ethnicity/Race

Years in Dental Profession (IF APPLICABLE)

Generational Category

Interest and Motivation

Why are you interested in serving on the NJ Dental Foundation Board of Directors? (Please provide a brief statement explaining your motivation for seeking this position and what you hope to contribute.)

What do you believe are the most pressing oral health issues in New Jersey today? (Please share your thoughts on key challenges and opportunities within the field of oral health.)

Experience and Skills

Please describe any previous volunteer or board experience, particularly related to health, education, or community service. (Include your roles, responsibilities, and achievements.)

What specific skills, expertise, or perspectives will you bring to the NJ Dental Foundation Board? (Highlight areas such as financial oversight, fundraising, strategic planning, community outreach, etc.)

Do you have experience with fundraising or development activities?

If yes, please describe:

Please provide any additional information or insights that you believe are relevant to your nomination. (Feel free to include anything else that would help the selection committee understand your suitability for this role.)

References

Please provide two professional references who can speak to your qualifications and suitability for board service.

Reference 1

Name

Email Address

Relationship

Phone Number

Reference 2

Name

Email Address

Relationship

Phone Number

Commitment

Board members are expected to commit time and effort to fulfill their responsibilities. Are you able to commit to attending regular board meetings and participating actively in board activities?

If no, please explain:

Signature

By submitting this form, you affirm that the information provided is accurate and complete to the best of your knowledge.

Full Name

Signature

This will serve as your signature.

Date

Submission

Please submit the completed form by December 18, 2024. If you have any questions, contact Gabby Rodriguez, grodriguez@njda.org or (732) 422- 2728.

Thank you for your interest in serving on the NJ Dental Foundation Board of Directors!

NJ Dental Foundation Board of Directors Nomination Form

Personal Information

Interest and Motivation

Experience and Skills

References

Reference 1

Reference 2

Commitment

Signature

Submission

General Information

Sections

Resources