Bland County Medical Clinic

Bland County Medical Clinic

Board Member Application
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PhoneEmail
Current Occupation/Title
Employer/Organization
Industry/Sector Experience*
YesNo
If yes, please describe your role and contributions:
Why are you interested in serving on the board of our organization?*
What skills, experiences, or resources do you bring to the board? (List relevant skills, such as financial, legal, fundraising, marketing, etc.)*
References

Please provide two references (name, phone, email)
Reference Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reference Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Is there anything else that you would like us to know about you?
A health center board member may not be an employee of the center, or spouse or child, parent, brother or sister by blood or marriage of such an employee.

The Board of Directors providers leadership and governance to support the health center's mission. The board is responsible for strategy, oversight and policy, and board functioning. The board carries out its governance functions as a group during board meetings. It delegates day-to-day operations and management to the Chief Executive Officer (CEO). The board and CEO work in partnership to support the long-term sustainability of the center.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Bland County Medical Clinic

References