(This form is a public record, but subject to the protection of the Information Practices Act) 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field. Ensure that you print or type clearly for legibility.
3. Fill in your address, including street, city, state, and zip code. This information is crucial for communication purposes.
4. Provide your phone numbers: work, home, and cell. This allows the committee to reach you easily.
5. Enter your email address accurately to facilitate electronic communication regarding your application.
6. Select the category you are applying for by checking one of the options: Dentist, Dental Auxiliary, Physician/Psychologist, or Public Member.
7. Indicate which committee you wish to join by selecting either Northern DEC or Southern DEC.
8. Input your California License Number and Social Security Number (SSN), noting that SSN is mandatory except for public member applicants.
9. In the provided space, summarize your professional and educational experience relevant to this application.
10. Share your philosophical beliefs regarding chemical dependency treatment in the designated area.
11. Read and acknowledge understanding of responsibilities and time commitments by signing and dating at the bottom of the form.

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