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Apply to Become a Board Member

Name *

First

Last

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Prefix:

Name prefix: Mr, Mrs, Ms, MS, Dr

Email *

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Cell Phone: *

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Work phone:

Home phone

Have you ever used, or have you ever been known by, any other name?

If yes, provide name(s) and explain:

Please provide links to any of your active social media profiles:

Home Address Line 1 *

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Home Address Line 2

City *

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State *

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Zip *

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Work Address Line 1

Work Address Line 2

City

State

Zip

Area(s) of Expertise: *

Public Safety
Social Services
Public Relations/Press
Planning
Managerial
Legislative
Juvenile Services
Information Technology
Human Resources
Housing
Health
Executive
Environment
Education
Economic Development
Business Development
Budget
Administration
Non-profit
Law enforcement
Other

Select all choices that are applicable to you

If you chose 'Other' for the question above, please describe your area of expertise:

Resume *

Please paste a copy of your TEXT RESUME here

Honors:

Please list all scholarships, fellowships, honorary degrees, honorary society memberships, and other special recognition for outstanding service or achievements.

Previous Board Appointments

Please list any previous board appointments that you have held: Position, dates, and organization.

References: *

Please list the name, telephone number and e-mail address of three (3) persons who are willing to serve as references.

Military Service (if applicable):

List rank, date and type of discharge from active service

Were you discharged from military service under anything less than honorable conditions?

No
Yes

If yes, please explain:

Are you a member of the Reserves or the National Guard?

Yes
No

If yes, what date does you obligation end:

Professional Licenses:

Please list any professional licenses you hold, and the state in which the license is registered.

Business / Lobbying: Describe any business relationship, dealing or financial transaction which you have had during the last five years, whether for yourself, on behalf of a client, or acting as an agent which you believe may constitute an appearance of impropriety or could result in a potential conflict of interest in the position to which you want to be appointed. If none, please state. *

Are you or have you at any time, been a registered lobbyist? *

Yes
No

If yes, please provide the name of the organization(s) for which you lobbied:

Citations: Have you ever been cited for a breach of ethics for unprofessional conduct, or been named in a complaint to any court, administrative agency, regulatory body, professional association, disciplinary committee, or other professional group? *

Yes
No

If yes, please provide a detailed explanation:

Convictions: Have you ever been convicted of or entered a plea of guilty or nolo contendere or forfeited collateral for any criminal violation other than a minor traffic offense? (Minor traffic offenses do not include the State offenses of operating under the influence of liquor, operating while impaired, reckless driving or the equivalent offenses in other states) *

Yes
No

If yes, please provide a detailed explanation:

Current Charges: Are you now under charges for any violation of law? *

Yes
No

If yes, please provide a detailed explanation:

Opposition / Associations: Do you have any expectations of any group or individual voicing concern about your possible appointment? *

Yes
No

If yes, please provide a detailed explanation:

Delinquencies: Are you delinquent on any federal, state, or local debt? (Include delinquencies for income, property, or other taxes, governmental loans, overpayment of benefits, required payments into or under governmental programs, and other debts or required payments to the government plus any defaults on or under loans which are or where guaranteed, insured, or subsidized by any unit of government.) *

Yes
No

If yes, please provide a detailed explanation:

Issues: In the last five years, have you been publicly identified, in person or by organizational membership, with a particularly controversial national, state or local issue? *

Yes
No

If yes, please provide a detailed explanation:

Submission of Views: In the last five years, have you submitted oral or written views to any governmental authority, whether executive or legislative, or to the news media on any particularly controversial issue other than in an official capacity? *

Yes
No

If yes, please provide a detailed explanation:

Agency Proceedings / Civil Litigation: In the last five years, have you been, or are you presently a party of interest in any administrative agency proceeding or civil litigation, including any action regarding a professional license? *

Yes
No

If yes, please provide a detailed explanation:

Civil Litigation of Affiliates and Family: In the last five years, has any business in which you, your spouse or partner, any member of your household or other close family members or business associate are or were any officer, director or partner been a party to any administrative agency proceeding or civil litigation relevant to the position to which you have been appointed? (With respect to this question, you need only consider proceedings and litigation that occurred while you, your spouse, close family member or business associate were an officer of that business.) *

Yes
No

If yes, please provide a detailed explanation:

Legal Proceedings: Have you ever been a party or otherwise involved in any legal proceedings – civil or criminal? Include all legal proceedings in which you were a party of interest, a material witness, the subject of a complaint, were named as a co- conspirator or co-respondent, and any grand jury investigation in which you figured as a subject, or in which you appeared as a witness. Do not list proceedings in which you were merely a nominal party where no allegations of wrongdoing were alleged against you. *

Yes
No

If yes, please provide a detailed explanation:

Charges / Associates: Has a criminal charge been brought against any firm or organization during your affiliation with it? *

Yes
No

If yes, please provide a detailed explanation:

Discrimination: Has a complaint of discrimination on the basis of sex, race, religion, national origin, age or handicap ever been filed against you or against any firm or organization during your affiliation with it? *

Yes
No

If yes, please provide a detailed explanation:

Credit History: Have you ever experienced credit difficulties? Have you ever filed for bankruptcy, or encountered other severe financial difficulties? *

Yes
No

If yes, please provide a detailed explanation:

Controversy: Is there anything in your personal or professional life that would cause controversy for you or Healing Arts Institute during a review of your candidacy or your service as a board appointee? *

Yes
No

If yes, please provide a detailed explanation:

Affiliations: Please list each organization, club, association, or group that you are, or have been a member of, in the past five years. *

The following optional information is requested in order to ensure that we consider the talent and creativity of a diverse pool of candidates. You may wish to provide this information in order to ensure that you are considered for relevant boards and commissions. Date of Birth:

What are you passionate about? Feel free to include anything that you beleive is relevant to your personal interests and expereinces.

U.S. Citizen?

Yes
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Gender

Male
Female
Other identity

Differently abled person? (specify):

Ethnicity:

African American
Arab / Middle Eastern
Asian Pacific Islander
Caucasian
Hispanic
Indian
Native American
Other

Country of Birth:

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