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Certificate For International Volunteer Service Application

  The Certificate for International Volunteer Service recognizes ADA members who have volunteered their time for at least 14 days in a 24 month period outside the U.S. to improve the oral health of underserved populations. The nominee must be a member of the ADA and a testimonial letter from the nominee’s dental society or dental school and volunteer organization must be received by the ADA Division of Global Affairs in order for the nomination to be considered by the ADA Committee on International Programs and Development. Please fill out the following form based on the nominee's information and the details of the volunteer service provided. Nominations and supporting materials must be submitted by April 1.

  All fields marked with an * are required in order to submit nomination
 
Part I.  Nominee Information
*ADA Member #: (no dashes)  
*First Name:
*Last Name:
*Address 1:
 Address 2:
*City:
*State:
*ZipCode:
*Submitted By:
Nominee
Other
*Mailto: Dental School / Society
Nominee
Check all that apply and enter total average number of hours worked per day within specified date range. Use additional areas for multiple service descriptions.
Part II. Service Description
Country of Service:
Sponsor/Program:
Start Date:(mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Patient Teaching/Training
Community Teaching/Training
Oral Surgery (extractions)
 Restorative
 Preventative
Diagnostics
Other: 
Hrs Per Day:    
Country of Service:
Sponsor/Program:
Start Date:(mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Patient Teaching/Training
Community Teaching/Training
Oral Surgery (extractions)
 Restorative
 Preventative
Diagnostics
Other: 
Hrs Per Day Total:  
Part II. Con't
Country of Service:
Sponsor/Program:
Start Date:(mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Patient Teaching/Training
Community Teaching/Training
Oral Surgery (extractions)
 Restorative
 Preventative
Diagnostics
Other: 
Hrs Per Day Total:  
Country of Service:
Sponsor/Program:
Start Date:(mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Patient Teaching/Training
Community Teaching/Training
Oral Surgery (extractions)
 Restorative
 Preventative
Diagnostics
Other: 
Hrs Per Day Total:     
 
  Part III.  Testimonial Letter-Must be received by April 1 deadline
  a. A testimonial letter from the volunteer organization’s onsite administrator or appropriate official, verifying that the above stated volunteer service was performed as described is required. The letter requires the following: Name of Administrator Supplying testimonial, telephone, organization and address.  
   
  b. A testimonial letter from the dental society or dental school of the nominee confirming that the member or student is currently in good standing is required. The nomination must be recognized by the dental society or dental school or it will not be complete. The letter requires the following: Name of society or school, name of dental society or dental school officer, professional title, and signature.
 
  Testimonial letters should be sent to the ADA Division of Global Affairs, 211 East Chicago Ave. Chicago, IL 60611 or e-mailed to international@ada.org. If numerous individuals are being nominated from the same dental society, school or volunteer organization, one testimonial letter listing the nominees will satisfy the requirement.
   
  Questions? Please contact the ADA Division of Global Affairs, 312.440.2726.
 
    
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