Board of Directors Application

Date of Birth

Street Address

Address Line 2

Brief description of educational background:

Interest and expertise, what you would contribute to the Board:

How did you hear about the opportunity to join the Board?
Board MemberEmployeePatientWebsiteOther

Please select the 2 committees on which you would be most interested in serving (select only 2 committees)*:
Nomination Board Orientation and Board Development Committee (HR Planning Team)Performance Improvement Committee (Products & Services Expansion Planning Team)Finance Committee (Financial Planning Team)Marketing & Public Relations (Development Planning)Strategic Planning (Strategic Alliance Planning Team)

Are you an active patient of Open Cities?
YesNo