2024 New York County Dental Society Board Application


  • 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. 

Please email the completed 2024 Application, your CV, and your Position Statement to: 

All applications must be received at NYCDS by Friday, June 16, 2023 at 4:00 PM. Late applications will not be accepted. Candidates must be available to meet virtually on July 18 or 19. 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 16 applications due at NYCDS 

June 26 applicants notified of date and time of interview 

July 18-19 interviews conducted

July 20 results announced 

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

For example: "New York County Dental Society, 2012"
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"
New York County Dental Society
New York State Dental Association
American Dental Association
Dental Specialty Organization
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"
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."
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.
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?
If yes, please provide details.

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 16, 2023 at 4:00 PM.

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