Application to Become a Director

Contact Information

Surname: (required)
First Name: (required)
Home Address: (required)
City: (required)
Province: (required)

Postal Code: (required)
Home Phone Number: (required)
Business Phone Number: (required)
Email Address: (required)
Preferred Method of Contact: (required)Home PhoneBusiness PhoneEmail

Qualifications

I, the undersigned, hereby apply to be considered for appointment as a Director of the Corporation, and in doing so, acknowledge and declare that:

1. Are you an employee, the spouse, common-law partner, child, parent, brother, or sister of a member of the Professional Staff who have privileges or of an employee of the Hospital, or any other relationship that would impede your independence of decision making?---YesNo
2. Have you been an employee of the organization anytime within the last three (3) years?---YesNo
3. Are you a municipal, provincial or federal officeholder or elected official?---YesNo
4. Are you under the age of eighteen (18) years?---YesNo
5. Do you have an undischarged bankruptcy?---YesNo

If you have responded YES to any of the above questions (1 through 5), unfortunately you are not eligible for election or appointment as a Director of the Corporation.