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I, the undersigned, hereby apply to be considered for appointment as a Director of the Corporation, and in doing so, acknowledge and declare that:
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?—Please choose an option—YesNo
Have you been an employee of the organization anytime within the last three (3) years?—Please choose an option—YesNo
Are you a municipal, provincial or federal officeholder or elected official?—Please choose an option—YesNo
Are you under the age of eighteen (18) years?—Please choose an option—YesNo
Do you have an undischarged bankruptcy?—Please choose an option—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.
Please describe your interest in serving as a Director of the Corporation and any other information you would like to offer.
50 College Drive,
P.O. Box 2500
North Bay, ON
680 Kirkwood Drive,
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