ADA REFERENCE COMMITTEE WRITTEN TESTIMONY

This form must be completed in full and sent to the appropriate Reference Committee email address to be processed.

rca@ada.org – Reference Committee A (Business, Membership and Administrative Matters)

rcb@ada.org – Reference Committee B (Dental Benefits, Practice, Science, Health and Related Matters)

rcc@ada.org – Reference Committee C (Dental Education and Related Matters)

rcd@ada.org – Reference Committee D (Legislative, Governance and Related Matters)
To be considered by the reference committee, testimony must be received
no later than 5:00 pm Eastern Time on Monday, October 20.

**All fields are required**

Resolution Number:

Reference Committee (A,B,C,D):

Pro Testimony

Con Testimony

Submitted By:

Date Submitted:

Affiliation

District:

Organization:

In accordance with the ADA Disclosure Policy, at the appropriate time anyone present at this meeting is obligated to disclose any personal, professional or business relationship that they or their immediate family may have with a company, professional organization or individual doing business with the ADA, when such company, professional organization or person is being discussed. This includes, but is not limited to insurance companies, sponsors, exhibitors, vendors and contractors.

I have read the disclosure policy

I have read the disclosure policy and would like to disclose the following:

Written Testimony: