Board Application Form

Instructions

To apply to be a member of the West Parry Sound Health Centre Board of Directors, you must complete this form and submit it with a copy of your current resume or a brief biographical sketch.

Applicant Contact Information

Surname(Required)

First Name(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Home Phone Number

Business Phone Number

Email(Required)

Preferred Method of Contact

Home Phone

Business Phone

Eligibility Criteria and Conditions of Appointment

Directors must be at least 18 years old. Undischarged bankrupts are ineligible to serve as directors. A director is expected to commit the time required to perform board and committee duties. The minimum time commitment is likely 10-15 hours per month. Directors must fulfill the requirements and responsibilities of their position, for example, preparing for and attending board and committee meetings, upholding their fiduciary obligations and working cooperatively and respectfully with other board members. Directors must comply with legislation governing the corporation, the corporation’s by-laws and policies, and all other applicable rules. Directors must sign a Declaration confirming their agreement to adhere to their fiduciary duties and board and corporate policies.

Conflict of Interest Disclosure Statement

Directors must avoid conflicts between their self-interest and their duty to the corporation. In the space below, please identify any relationship with any organization that may create a conflict of interest, or the appearance of a conflict of interest, by virtue of being appointed to the board.

Knowledge, Skills, and Experience

The board seeks a complementary balance of knowledge, skills, and experience. Please indicate your areas of knowledge, skills, and experience by listing below.

Please list current or prior board experience.

Which areas of board work are of particular interest to you?

Please describe any linkages you have or may have had with other similar organizations or entities in the same sector.

Declaration

By submitting this application, I declare the following:

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Name

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