<p> American Academy of Periodontology AAP Volunteer Registry Application Form</p><p>Please submit this form by saving the document and e-mailing it as an attachment to [email protected]. Questions - contact Eileen Loranger(800-282-4867. Date Name Address 1 Address 2 City State Zip E-Mail</p><p>Education Degree Year Granted Granted By Degree Year Granted Granted By Degree Year Granted Granted By Degree Year Granted Granted By</p><p>Board Certified (indicate yes or no)</p><p>Professional Concentration (indicate percentage spent in each area) Private Research Teaching Administration Practice</p><p>Last Updated – January 2016 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</p><p>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</p><p>Last Updated – January 2016 AAP Committee Interest:</p><p>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)</p><p>Administrative Committees  State and Regional Assembly Coordinating Committee - three positions  Volunteer Qualifications and Awards Committee - three positions</p><p>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</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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:</p><p>Reference #1 Name E-Mail Address Phone Number</p><p>Reference #12 Name E-Mail Address Phone Number</p><p>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.</p><p>Last Updated – January 2016 SAMPLE CV</p><p>Harry J. Olsen, DDS 1234 Any Street, Suite 230 318-444-2345 (cell) [email protected]</p><p>EDUCATION 1998-2002 University of ______School of Dentistry Dental Any City, USA 22222 Degree: D.D.S., June 2002</p><p>1994-1998 University of Indiana College Hammond, Indiana Degree: B.S. Bacteriology, May 1998</p><p>EMPLOYMENT EXPERIENCE 1988-1994 Dentech Dental Laboratory 999 Walnut Street Pasadena, California Duties: Manager, Prosthetic Lab</p><p>HONORS AND AWARDS 1998 John Sullivan Scholarship (3.75 GPA) 2001 Omicron Kappa Upsilon 1991-2001 Dean’s List (all semesters) University of ______School of Dentistry</p><p>OTHER EDUCATON OF NOTE 5/2000-11/2000 Alameda County Hospital Hospital Dentistry Internship</p><p>PRINCIPLE PROFESSIONAL INTEREST 2002-present Solo General Practice Any City, California</p><p>RECENT PUBLICATIONS List Most Recent Publications Here</p><p>MEMBERSHIPS IN PROFESSIONAL ORGANIZATIONS 2002-present American Dental Association California Dental Association ______Dental Society</p><p>2003-present Southwest Esthetic Study Club San Clemente, California</p><p>POSITIONS HELD IN PROFESSIONAL ORGANIZATIONS 2004 Member, CE Program Committee ______Dental Society</p><p>PROFESSIONAL REFERENCES G.V. Black, Professor of Restorative Dentistry Chicago, Illinois 318-333-2222</p><p>ANY ADDITIONAL EXPERIENCE SIMILAR TO THAT REQUIRED FOR THE POSITION(S) APPLIED FOR?</p><p>Last Updated – January 2016</p>