CCIHSS

Candidate Information

First NameLast NamePhone NumberEmailAddressCityProvince– Select –AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal codeAre you employed?– Select –YesNoName of companyPosition

Background & Experience

Board Experience: Please list any board service experience, volunteer work, special training, skills, professional membership, community activities, hobbies, special interests that may be useful to your board placement.Professional experience: Please provide a brief summary of your professional background and experience

Skills & Expertise

Please check the areas where you have expertise that could benefit CCIHSS board. Check all that apply Governance Strategic Planning Human Resource Financial Management Legal Expertise Information Technology Seniors Community Engagement Communications Youth/Child Disability Women and Girls Program Development Social Services Health and Human Services Fundraising Other Please specifyAdditional Skills and Qualifications (if applicable): Please describe any other skills, qualifications, or experiences that would make you a valuable addition to our board.

Motivation & Aspirations

Please provide a brief statement explaining what interests you most in serving on CCIHSS’s board as well as your personal aspirations

Reference

Please provide the name and contact information of one reference who can speak to your qualifications for serving on our board.

NameRelationshipEmailPhone Number

Consent

I hereby certify that the information provided in this application is true and accurate to the best of my knowledge.
DateSubmit