Prefix: – Mr. Mrs. Ms. MS. Dr.
Name prefix: Mr, Mrs, Ms, MS, Dr
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 2 Work Address Line 1 Work Address Line 2 City State Zip Area(s) of Expertise: *
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
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.
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? If yes, please explain: Are you a member of the Reserves or the National Guard? 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? * 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? * 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) * If yes, please provide a detailed explanation: Current Charges: Are you now under charges for any violation of law? * 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? * 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.) * 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? * 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? * 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? * 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.) * 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. * 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? * 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? * 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? * 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? * 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. Differently abled person? (specify): Country of Birth: How did you hear about us?