Reference Committee Preferences Form

First Name

Last Name

State - Select - Alaska Idaho Montana Oregon Washington

Responsibility - Select - Delegate Alternate Other ADA Member Staff

Mobile phone # for District booklet

Are you attending the first Caucus meeting in Portland, OR on September 20 & 21?

• Yes
• No

What meals in Portland are you attending?

• Friday Dinner
• Saturday Breakfast
• Saturday Lunch

List any dietary restrictions:

Do you have a guest for Friday dinner? If yes, please name below:

I would like to add the following item to the agenda in Portland

Are you attending the second meeting of the Caucus in New Orleans on Saturday October 19?

• Yes
• No

Are you attending the third meeting of the Caucus in New Orleans on Monday October 21?

• Yes
• No

Are you attending the fourth meeting of the Caucus in New Orleans on Tuesday October 22?

• Yes
• No

I would like to add the following item to the agenda in New Orleans

I would like District 11 to consider introducing the following resolution

My First preference is: Committee A:Budget, Business, Membership and Administrative Matters Committee B:Dental Benefits, Practice, and Related Matters Committee C:Dental Education, Science, and Related Matters Committee D:Legislative, Health, Governance, and Related Matters

My Second preference is: Committee A:Budget, Business, Membership and Administrative Matters Committee B:Dental Benefits, Practice, and Related Matters Committee C:Dental Education, Science, and Related Matters Committee D:Legislative, Health, Governance, and Related Matters

My Third preference is: Committee A:Budget, Business, Membership and Administrative Matters Committee B:Dental Benefits, Practice, and Related Matters Committee C:Dental Education, Science, and Related Matters Committee D:Legislative, Health, Governance, and Related Matters

My Fourth preference is: Committee A:Budget, Business, Membership and Administrative Matters Committee B:Dental Benefits, Practice, and Related Matters Committee C:Dental Education, Science, and Related Matters Committee D:Legislative, Health, Governance, and Related Matters

Submit