Board of Directors Application

Gardner Health Services always welcomes individuals who are interested in joining our Board of Directors. As a Board member, you can use your skills and talents to help fulfill Gardner’s mission.

"*" indicates required fields

Full Name*

First Name Last Name

Address*

Home Phone Number

Work Phone Number

Mobile Phone Number*

Email Address*

Place of employment or other point of contact*

Do you currently use Gardner’s services?*

Yes

If yes to above question, which health center?

Date you started receiving services from us

Date of most recent appointment

I was referred by

1. I am interested in becoming a Board Member because:*

2. Qualifications and/or qualities that I feel make me a viable Board Member candidate:*

3. Past or present membership in advisory groups, organizations, etc. (list dates):*

Date 1

Date 2

Date 3

4. A. Are you related to any current Board Member by blood or marriage?*

Yes

4. B. Are you related to any current employee of this organization by blood or marriage?*

Yes

5. List 3 references other than family and include their phone numbers with area code. Or, attach 3 letters of recommendation.*

List References

Attach 3 Letters of Recommendation

Reference #1

Full Name*

Address*

Occupation*

Phone*

Reference #2

Full Name*

Address*

Occupation*

Phone*

Reference #3

Full Name*

Address*

Occupation*

Phone*

Attach 3 Recommendation Letters

Attach Recommendation Letters 1-3*

Drop files here or

Max. file size: 528 MB, Max. files: 3.

Experience:

6. List educational background degrees, etc. If available, please upload resume below.*

Upload resume

Drop files here or

Max. file size: 528 MB, Max. files: 2.

Consent*

I agree to the following:

I certify, that the statements made on this application, on any resume, and attachments hereto, or other supplementary materials provided by me, are full and complete statements of the facts. I understand that false, misleading or omitted information will result in refusal of membership to the Board of Directors or termination in cases where erroneous information is discovered after membership has begun. I understand that if I am offered membership to the Board of Directors and accept, this application form becomes part of the terms and conditions of membership.

Signature*

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Board of Directors Application

Reference #1

Reference #2

Reference #3

Attach 3 Recommendation Letters

Experience:

GET IN TOUCH

Gardner Health Services
Corporate Office
160 East Virginia Street, Suite 100
San Jose, California 95112

MEDICAL RECORDS

NOTICE OF PRIVACY PRACTICES

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Board of Directors Application

Reference #1

Reference #2

Reference #3

Attach 3 Recommendation Letters

Experience:

GET IN TOUCH

Gardner Health ServicesCorporate Office160 East Virginia Street, Suite 100San Jose, California 95112

MEDICAL RECORDS

NOTICE OF PRIVACY PRACTICES

Subscribe

Popular Keywords

Categories

Sign Up For Our Newsletter

Gardner Health Services
Corporate Office
160 East Virginia Street, Suite 100
San Jose, California 95112