2025 New York County Dental Society Board and NYSDA Trustee Application

BOARD ELIGIBILITy

  • EXECUTIVE COMMITTEE: Only Active Members, Life Members, and Retired Members, in good standing, who have completed three years on the Board of Directors, or have served as the Chair of a Committee for a minimum of four years, are eligible to hold the position of an elective office (President-Elect, Vice President, Secretary, Treasurer).  
  •  BOARD OF DIRECTORS: Only members who have served on a Committee for two years or more, or who have served as an Alternate to the Board of Directors, are eligible to serve on the Board of Directors as a Director at Large. 
  • NYSDA TRUSTEE: Only an active, life or retired member in good standing who has served at least three years in total that are accumulated from any combination of service in the following capacities: 1) as a delegate in the NYSDA House of Delegates; 2) as an alternate delegate in the NYSDA House of Delegates; 3) as a chair of a council of the Association shall be eligible to serve as a New York State Dental Association trustee.  

Please email the completed 2025 Application, your CV, and your Position Statement to: 

All applications must be received at NYCDS by Friday, June 7, 2024 at 4:00 PM. Late applications will not be accepted. Candidates must be available to meet virtually on July 9 or 10. Candidates may indicate their preference to be considered for more than one position by checking the appropriate boxes at the end of this form.


June 7 applications due at NYCDS 

June 14 applicants notified of date and time of interview 

July 9-10 interviews conducted

July 11 results announced 

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PERSONAL DATA
Full name
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Email
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ADA Number
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Office Address
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Telephone (Office)
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Telephone (Cell)
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Dental Degree and Date Earned
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Please indicate the position for which you wish to be considered for Elective Office or Board of Directors (select only one):
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If you are not nominated for the position checked above, please indicate your interest in another position:
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OTHER PROFESSIONAL MEMBERSHIPS
Please list other professional memberships, with the name of the membership group and your date joined.

For example: "New York County Dental Society, 2012"
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VOLUNTEER SERVICE
In the space provided, type in the positions held and the date of service for each of the following organizations, if applicable. Include all applicable board and committee positions.

For example: "GKAS Committee Chair, 2017-2021"
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New York County Dental Society
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New York State Dental Association
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American Dental Association
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Dental Specialty Organization
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OTHER SERVICE AND AWARDS
List all organizations and any positions held for which you have volunteered time for public service or oversite responsibilities such as religious institutions, cooperative boards and clubs. Include organization name, position held, and dates. 

For example: "Boys & Girls Club, Board Member, 2012-2021"
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List any awards you have received, including the purpose of the award and the date. 

For example: "ADA 10 Under 10 Award, demonstrate excellence and inspire others, received in 2019."
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Leadership Position Statement
Describe your qualifications, experience and leadership philosophy as to how you qualify for the position that you seek. 

How will you apply it in service to NYCDS? 

Keep your remarks to 500 or fewer words.
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Position Interest
Do you have any past or current professional issues that might be construed to reflect adversely on any leadership position for the profession or for the Society?
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If yes, please provide details.
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I agree to spend at least the time required if I am elected to serve. Further, I attest that, to the best of my knowledge, the information contained in this application is true and accurate and contains no significant omissions. 

 

I understand that the details of the deliberations and votes of the Nominating Committee are confidential. I will not contact any member of the Committee regarding my candidacy or their support of my application.  

 

I agree to abide by the NYCDS Conflict of Interest policy if I am nominated and elected. 

If you agree, please type your name below.
 *

Leadership Application, CV, and Position Statement must be emailed to: dlaurenzo@nycdentalsociety.org by Friday, June 7, 2025 at 4:00 PM.

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