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.