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BOARD MEMBER APPLICATION
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Full Name
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First
Last
Phone Number
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Email
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Address
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City
State
Zip Code
Country
List any and all other Associations or Organizations that you are affiliated with including any officer or board member positions:
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Please attach a copy of your Resume / CV
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Max file size: 20MB
Summarize your experience with and/or interest in our organization
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​What skills and knowledge are you willing to bring to our board?
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Please indicate your experience in the following areas.
Strategic planning
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Very experienced
Some experience
Little or no experience
Fundraising
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Very experienced
Some experience
Little or no experience
Recruiting, hiring and evaluating personnel
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Very experienced
Some experience
Little or no experience
Program planning and evaluation
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Very experienced
Some experience
Little or no experience
Financial management and control (budgeting, accounting)
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Very experienced
Some experience
Little or no experience
Communication, public and media relations *
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Very experienced
Some experience
Little or no experience
Information technology
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Very experienced
Some experience
Little or no experience
Legislative Affairs
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Very experienced
Some experience
Little or no experience
Other Skills
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Participation in interagency committees
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Very experienced
Some experience
Little or no experience
Writing, journalism, public relations
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Very experienced
Some experience
Little or no experience
Public speaking
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Very experienced
Some experience
Little or no experience
Special events (planning and implementing)
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Very experienced
Some experience
Little or no experience
For the items you checked as "very experienced" or "Some experience", please provide details.
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If not described above, please outline your experience as a volunteer board or committee member
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Upload a portrait picture of yourself
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Max file size: 20MB
Electronic Signature
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Type Full Name
By my electronic signature, I am confirming that I have accurately completed this application to the best of my ability and have not purposely omitted any information.
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Home
About
Contact
Board Of Directors
Become a Member
Physician Application