BOARD MEMBER APPLICATION

The mission of CPCA. is to enable and assist low-income people to attain skills, knowledge, motivation, and opportunities needed for them to become self-sufficient and independent.

Please complete the information below verifying your interest in becoming a member of the CPCA Board of Directors. Election to the CPCA Board of Directors will follow the procedures outlined in the agency by-laws and in accordance with specific program requirements.

I certify to the following statements:

• I am not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any federal department or agency;
• I have not been convicted of or had a civil judgment rendered against me or my company for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction, for violation of federal or state antitrust statutes or for commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
• I am not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state or local) with commission of any of the offenses above; and
• I have not had any public transactions (federal, state or local) terminated for cause or default during the three years prior to their application.

NOTE: If you cannot certify to the items above, please attach an explanation to the application describing the circumstances for the Board to consider. Making a false certification is cause for removal from the board and/or board consideration.

FOR BOARD USE ONLY

YES/NO	PROCESS	DATE
	Nominee has had a personal meeting with either chief executive, board chair, or other board member.
	Nominee reviewed by the committee.
	Nominee attended a board meeting.
	Nominee reviewed by the board.

Action taken by the board:_______________________________________________________________________________________

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Board Chair Signature ___________________________________ Date __________

Board Development

Committee Chair Signature _______________________________ Date __________