APPLICATION FOR PENINSULA HEALTH CARE DISTRICT BOARD

Term ends December 11, 2016

APPLICATION DUE BY NOON FEBRUARY 17, 2015

Name:

Home Address:

Telephone:

Email:

Occupation:

How long have you resided within the District’s boundaries?

Educational History:

Work History and Experience:

Public Offices Held (list dates and position):

Community Involvement or Services:

Please use a separate sheet(s) to answer the following questions:

  1. Why are you interested in serving on the Peninsula Health Care District Board?
  1. What would you hope to accomplish while holding this position?
  1. What skills do you possess which qualify you to fill this office?
  1. What experience do you have with the Healthcare industry, either professionally or personally?
  1. What experience do you have working with non-profit organizations and/or government agencies, especially ones providing healthcare related services?
  1. What’s your vision for the Peninsula Health Care District (in 100 words or less)?

I hereby certify that I am qualified to serve as a member of the Peninsula Health Care District Board. I legally reside within the Peninsula Health Care District boundary. I am a registered voter and I have completed a Form 700 Statement of Economic Interests which is submitted with this application. I understand that my application materials will be considered a public record and thus will be available for public inspection and copying. The completed applications may also be published on the District website.

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SignatureDate

IMPORTANT NOTICE

Completed applications and FPPC Form 700 Statements of Economic Interests must be received by the Peninsula Health Care District Office, 1600 Trousdale Drive, Suite 1210, Burlingame, CA 94010 by noon, February 17, 2015

Alternatively, a PDF version of the completed application packet and Form 700 may be submitted by e-mail to: , or faxed to (650) 652-9374 no later than noon, February 17, 2015

Eligible applicants will be promptly contacted to schedule an interview with the Nominating Committee of the Board.

Those wishing to express support of any particular applicant are asked to do so in writing. Letters of support may be addressed to the PHCD, Board of Directors and sent to 1819 Trousdale Drive, Burlingame, CA, 94010.

The Peninsula Health Care District Board will make a final decision on their selection at an open Board meeting no later thanApril 23, 2015.

ATTACH RESUME AND MAIL OR DELIVER APPLICATION BY NOON, February 17, 2015.

TO:Cheryl A. Fama, CEO

Peninsula Health Care District

1819 Trousdale Drive

Burlingame, CA 94010

Peninsula Health Care District Application

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