Examination Committee Application

Deadline for submission, September 1

First Name*
Last Name*
Email *
Email Confirm *
Address *
City *
State *
Zipcode *
Phone *
Fax *

Clinical Practice *

Clinical Setting *

Date of Board Certification *
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Date of appointment as Consultant
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Date of Renewal of Certification Process
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Date of attendance at the AAPD Comprehensive Review of Pediatric Dentistry *

Dates of attendance at AAPD Annual Session

Reference Name 1 *
Reference Email 1 *
Reference Name 2 *
Reference Email 2 *
Reference Name 3 *
Reference Email 3 *

Please review the information below:

Applicant must be a member of AAPD.

Agreement of Confidentiality:
I am aware that in my service as an EC member of the American Board of Pediatric Dentistry, I have access to and knowledge of confidential information, including board certification and examination information. I hereby agree to keep confidential all information I am privy to because of my service to the Board. Such information could include, but not be limited to, certification materials, examination results, discussion from Board meetings, education workshops, and examination critiques.
Furthermore, I hereby agree that any disclosure of confidentiality can be injurious to the reputation of the Board, and could result in litigation. Therefore, I agree to hold harmless the Board for any intentional breech of confidentiality on my part.

Statement of Personal Commitment:
If appointed, I will be available to participate in the annual meeting of my assigned subcommittee. My expenses will be covered per ABPD travel guidelines.

As an Examination Committee subcommittee member I will be available to actively participate via email and internet software as requested by the ABPD.

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