AMA Board Appointed Committee Application: American Dental Association Council

This form replaces the traditional paper application for AMA members seeking appointment by the AMA Board of Trustees to the AMA representative to the American Dental Association (ADA) Council on Advocacy for Access and Prevention.

If you need to save your application and return to it at a later time, click the "Save" button at the bottom of the page. You will receive an email with a link to return to your application.

If you have any questions, please email AMASections@ama-assn.org.

Position selection
Available American Dental Association on Advocacy for Access and Prevention positions

Physician representative

Supporting information
Current Professional Position and Responsibilities (i.e., practice, administrative, research, academic)*
Current/Prior State and Specialty Medical Society Memberships and Affiliations, and Faculty Appointments. (List current and past roles and positions held and dates of service).*
Current/Prior Membership on AMA Councils/Committees: (List Councils or Committees and dates of service). *
Applicant’s Statement of Interest *

(Not less than 50, nor more than 250 words.)0/250
Describe your professional interactions with the dental community.*
Sponsor's Narrative Statement (optional)

(Not less than 50, nor more than 250 words)0/250
Sponsor name (if applicable):

Executive Curriculum Vitae
Upload your executive curriculum vitae, which may not exceed three pages. Submissions longer than three pages will be truncated. *

Browse Files
.PDF; only first three pages will be published. Cancelof

Diversity Information
Your response to the question below will be shared on an as-needed basis only with limited AMA staff and AMA Board of Trustee members in the internal deliberation of applicants for purposes of creating a balanced group of individuals forming AMA councils/committees. The information provided will be kept confidential and will be stored on secure AMA servers in password protected folders. Additional information on AMA processing of this information is available in its Privacy Notice, available at https://www.ama-assn.org/about/privacy-policy, which has been made publicly available. Your response to the question below is completely voluntary. If, at any time, you decide you would like to make changes to or revoke permission for the AMA to use the information submitted in response to the following question, you may complete the AMA Data Privacy Request Form.
Please indicate your selection below.*

Yes. I authorize the AMA to process my information as described above.No. I choose NOT to agree to the processing of my information as described above.
Please describe a) how you have demonstrated a commitment to diversity in the past, and b) how you would show a commitment to diversity to the position for which you are applying.

250 words max0/250

Click "submit" below to finalize and transmit your application. You will receive an email confirmation with a copy of your application.

Please direct any questions to AMASections@ama-assn.org.
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About the Council