2023-25 Wisconsin Oral Health Coalition Membership Enrollment/Renewal

The Wisconsin Oral Health Coalition (WOHC) requires renewal of membership every two years. Please complete the following survey questions to maintain your membership, or to become a new member of the WOHC.

Question Title

* 1. Please enter today's date

Date

Date

Question Title

* 2. Last Name

Question Title

* 3. First Name

Question Title

* 4. Credentials

Question Title

* 5. Email Address

Question Title

* 6. Job Title

Question Title

* 7. Company/Representing

Self

Institution or agency

Name of institution or agency

Question Title

* 8. Address

Address

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

Question Title

* 9. How did you find out about the coalition?

Question Title

* 10.
Wisconsin Oral Health Coalition

Conflict of Interest Policy

A. All members of the Wisconsin Oral Health Coalition shall scrupulously avoid conflicts - both potential and real - between their own personal or financial interests/benefits and those of Wisconsin Oral Health Coalition.
B. All members of Wisconsin Oral Health Coalition shall scrupulously avoid conflicts - both potential and real - between the financial interests/benefits of their company or organization or agency and those of Wisconsin Oral Health Coalition.
C. When there is doubt, by any member of the voting group, as to whether a conflict of interest exists, the matter shall be resolved by a vote of the appropriate committee. In the case of conflict of interest during a general membership meeting of the Wisconsin Oral Health Coalition, the full voting group will vote on the matter of conflict. If the voting group decides that the matter would be a conflict of interest for the particular member, the following procedure will be used:
a. The member with the conflict of interest shall abstain from using personal influence on the matter. This does not preclude the member from entering into discussion on the matter or providing information that would assist in decision making for the voting members.
b. The member with the conflict of interest shall be absent from the room during the vote on the matter.
c. The minutes of the meeting in which the matter is discussed and voted upon shall reflect the member’s disclosure and abstention from voting.
D. If it is perceived, by any voting member of the group, that the member with the identified conflict is using undue or inappropriate personal influence, the voting member may call for a vote of the group that would disqualify the member with the conflict from taking part in any discussion on the matter.
E. The member with the conflict of interest may be counted for determining whether a quorum is present for the vote.
F. Members will attend meetings with intentions for fair and honest dealing with other members and the matters of the meeting.
G. Each member of the Wisconsin Oral Health Coalition shall be given a copy of this conflict of interest policy.

The conflict of interest policy shall be reviewed at the annual meeting to inform and guide members of the Wisconsin Oral Health Coalition. Any new members shall be advised of the provisions of this policy upon joining the Wisconsin Oral Health Coalition.

I verify that I have read and that I agree to abide by the attached Wisconsin Oral Health Coalition Conflict of Interest Policy posted above. If yes, initial in the box below.