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Are you nominating yourself or another COHA member?
(Required.)
Myself
Another COHA member
NOMINATOR INFORMATION
If you are nominating somebody, please provide your information:
First Name
Last Name
Email Address
Mobile number
NOMINEE INFORMATION
Provide the following information in full about the hygienist you
are nominating.
*Required Fields
*
First Name
(Required.)
*
Last Name
(Required.)
*
Email Address
(Required.)
*
Mobile number
(Required.)
*
Profession
(Required.)
Dental Hygienist
Dental Hygiene Faculty
Other
*
Are you a member of the COHA Facebook Community?
(Required.)
Yes
No
Not sure
*
How many practices do you work in?
(Required.)
1
2
3+
*
Years in Practice
(Required.)
1-6
6-10
11-20
21-25
26-30
30+
*
MAIN PRACTICE INFORMATION ( Where you spend most hours)
(Required.)
Practice Name
Practice Address
Practice City
Practice State
Practice Postal Code
Practice Main Phone Number
*
Practice Setting
(Required.)
Private Practice
Public Health
DSO/Corporate
*
Practice Type
(Required.)
General
Periodontal
Pediatric
Orthodontic
Other
Why you are recommending yourself or your nominee to serve on the COHA Board?
Please explain why you or your nominee is qualified to serve on this board.
*
View the
COHA Advisory Board Terms and Conditions.
(Required.)
I agree to these Terms and Conditions.