2025 Society Profile & Delegate Form 2025 Society Profile & Delegate Form Date MM slash DD slash YYYY Society NameEIN #Street address, City, ST, ZIP CodePerson Completing FormPrimary phone numberOther phone numberEmail address Facebook AddressInstagramTwitter2025 Delegates: Please identify your delegates for the 2025 NDA Annual Convention. You may attach an additional sheet if necessary.Please List Society OfficersTerm Start DatePlease List Society OfficersTerm End Date: PresidentEmail President - ElectEmail Vice PresidentEmail Secretary (Corresponding/Recording)Email TreasurerEmail Financial SecretaryEmail Community Outreach ChairEmail Newsletter EditorEmail Geographic Area:# of Society Members:# of Potential Members:General Population:# of NDA Dues Paying Members :# of Volunteer Members:Dental Public Health Facilities:CAPTCHA
