HOSPICE LENNOX AND ADDINGTON ASSISTS AND SUPPORTS CLIENTS, CAREGIVERS AND THEIR FAMILIES WITH LIFE-THREATENING ILLNESS AND OFFERS BEREAVEMENT CARE AFTER LOSS. OUR VISION IS TO PROVIDE COMPASSIONATE CARE AND SUPPORT TO EVERY PERSON IN OUR COMMUNITY LIVING WITH A LIFE-THREATENING ILLNESS SO THEY MAY REACH THE END OF THEIR LIFE WITH DIGNITY.

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* 1. Name & Contact Information (note: middle name required for CPIC application letter)

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* 2. Address

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* 3. Birthdate

Date

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* 4. Background Information

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* 5. Why do you wish to be on the Board of Directors for Hospice L&A?

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* 6. Please list any areas in which you have experience or expertise:

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* 7. Please describe any skills, background or experiences that you feel would be relative to the purpose and goals of Hospice L&A. Please include any volunteer experience that you have, including any Board of Director positions held.

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* 8. Are you aware of any real or perceived conflict of interest, which exists or could present in the future in connection with your duties as a member of Hospice L&A's Board of Directors? If so, please describe.

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* 9. Are you prepared to make a two-year commitment to Hospice L&A?

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* 10. Anything else you would like to share with us?

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* 11. Please provide two references whom we may contact.

Reference #1

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* 12. Reference #2

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* 13. By selecting "I agree" below, you declare that the above information is true and complete to the best of your knowledge. Furthermore, should you accept an offered position on the Board of Directors, you promise to honestly and faithfully perform your duties and responsibilities to the best of your abilities in accordance with all laws and regulations.

Note: Board members are required to submit an up to date CPIC, complete a confidentiality agreement and maintain membership with Hospice Lennox & Addington for the duration of their term ($5/year or $20/5 years).

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