Governance Application Form - The Royal College of Dentists of Canada

The member-at-large is a Fellow in good standing at the Royal College of Dentists of Canada wishing to participate in one of the selected committees of the Board of Directors. Each committee has unique objectives and responsibilities that contribute to the daily and long-term success of the College. Please visit the website for full descriptions of each committee.

Section A: Personal Information

Name

Specialty

Address

City/Town

Province/State

Postal Code/Zip Code

Country

Phone

Cell Phone

Email Address

Year Fellowship Conferred

Please state any previous involvement with the College:

Please select all committees of interest to your application in order of importance. *Leave
blank the committees that are of no interest.

Early Career Fellows Committee

International Fellows Committee

Budget and Audit Committee

Governance Committee

Credentials Committee

Fellowship Affairs Committee

Section B: References

Reference Name

Relationship

Phone Number and/or

Reference Name

Relationship

Phone Number and/or

Section C: CV

Please upload a current CV below.

BROWSE YOUR COMPUTER

Section D: Special Accommodations

Do you have any special considerations or limitations that the College would need to
accommodate?

Section E: Agreement

By clicking yes below, you agree to the following:
The Royal College of Dentists of Canada is committed to receiving and treating personal
information in confidence. The information in this application form is collected and used by and
on behalf of the College for the purpose of evaluating the applicant’s eligibility and for any
correspondence or necessary recordkeeping. I hereby declare that all information provided in
this application is true and accurate, I authorize and consent to the College making inquiries of
third parties as are necessary to evaluate my eligibility and I acknowledge and understand that
any inaccuracy or misrepresentation will be grounds for immediate dismissal.
Yes

BACK