BOARD OF DIRECTORS MEMBERSHIP FORM
INSTRUCTIONS: We are required by the U.S. Department of Health and Human Services to collect the information below on every Board member. By law, the information can be used only for the purposes required by law (e.g., to report to the Centers for Medicare and Medicaid Services (CMS). This means the information will be kept secured, confidential, and available only to the CEO and his/her assistant for the purposes required by law.
First Name *
Your answer
Last Name *
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Street Address *
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City *
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State *
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Zip Code *
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Contact Phone Number *
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Mobile Phone Number
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State/Territory/Province of Birth *
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Country of Birth *
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Board Member Experience *
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Why would you like to join WNCCHS’s Board? *
Your answer
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