Application for Board of Directors

Thank you for your interest in becoming a member of the PrimaryOne Health Board of Directors or serving on a Board Committee. All candidates are asked to complete an application to allow the Board to become familiar with the applicant's background, interests, professional associations and community involvement. An interview will be scheduled with the Nominating Committee after submission of the application.

Question Title

* 1. Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Are you a current PrimaryOne Health patient?

Yes

If not, are you willing to become a patient, either primary care, dental, vision and etc?

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* 3. Are you related to an employee of PrimaryOne Health?

Yes

If you answered yes, who is the employee and what is the relationship?

Question Title

* 4. Employment

Current Employer

Title/Position

Question Title

* 5. Relevant Employment History and/or Experience
(you can also email your resume to daisha.burston@primaryonehealth.org)

Question Title

* 6. What skills and talents would you bring to the Board to contribute to the success of PrimaryOne Health?

Question Title

* 7. Please tell us about your volunteer history and current volunteer commitments

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* 8. Please tell us why you are interested in joining the PrimaryOne Health Board of Directors

Question Title

* 9. I have reviewed the Mission, Vision and Values statements, and I am aware of the time commitment and duties of a Director

Legal name

Date

Question Title

* 1. Contact Information

Question Title

* 2. Are you a current PrimaryOne Health patient?

Question Title

* 3. Are you related to an employee of PrimaryOne Health?

Question Title

* 4. Employment

Question Title

* 5. Relevant Employment History and/or Experience(you can also email your resume to daisha.burston@primaryonehealth.org)

Question Title

* 6. What skills and talents would you bring to the Board to contribute to the success of PrimaryOne Health?

Question Title

* 7. Please tell us about your volunteer history and current volunteer commitments

Question Title

* 8. Please tell us why you are interested in joining the PrimaryOne Health Board of Directors

Question Title

* 9. I have reviewed the Mission, Vision and Values statements, and I am aware of the time commitment and duties of a Director

* 5. Relevant Employment History and/or Experience
(you can also email your resume to daisha.burston@primaryonehealth.org)