Governing Board Candidate Information Form
This form is to be completed by anyone applying to be a candidate for the CISV International Insurance Company Board. Please send italong with your CV to the persons and email addresses indicated in the CISV International Insurance Company Board Member - Role Profile and Application Procedure.
Full name ofcandidate:
National Association and Chapter
E-mail address:
Date of birth (yyyy/mm/dd):
PART 1 Candidate Attitude, Skills and Knowledge
Please describe the following. Enter as much as you like; the boxes will expand. Please also attach your C.V.
Educational background:
Professional background:
Volunteer experience (including CISV):
With reference to the CISV International Insurance Company Board Member - Role Profile and Application Procedure in mind, briefly describe why you are applying for this position.

PART 2: Candidate Self-Certification

Members of the CISV International Insurance Company Board (Directors) hold a position of great trust. In order to protect CISV International’s reputation and integrity and the children and other participants in our care, there are some specific restrictions that need to be taken into consideration. There are also requirements set out in the applicable legislation. CISV International and CISV International Insurance Company, therefore, require that appropriate background checks be made on individuals applying to beDirectors. We also require thatyou confirm the following.

  1. I acknowledge that I am a current member, in good standing, of the CISV National Association and/or Chapter noted at the top of this form.

  1. I have informed my National Association of my application.

  1. I consent to a criminal record check and will give my National Association or Chapter any information required for them to conduct a criminal recordcheck on me.

  1. When requested, I will request that two references be supplied to CISV International.

  1. I do not have a history of criminal activity that would prevent me from serving as a Director of CISV International Insurance Company. Specifically:
  • I am not listed on a national Child Protection Register
  • I have not been charged with or convicted of serious criminal activity. Serious criminal activity includes, but is not limited to: murder; a serious sex offence; an offence committed by an adult involving intentionally wounding or causing grievous bodily harm; indecency offences punishable by imprisonment of 12 months or more; kidnapping; offences connected with child prostitution or child pornography.
  • I have not been convicted of any offence involving dishonesty or deception
  • I am not, to the best of my knowledge, information or belief, currently under investigation, nor have I been convicted of corruption, human rights abuses, arms, drugs or persons trafficking, transnational organized crime or any other crime that is, or could be considered to be, contrary to the mission, values and purpose of CISV

  1. I am not and in the last 10 years, I have not been a member of any kind in any of the following organizations or groups:
  • Persons or groups included in the UN, US or EU terrorist organizations list
  • Persons or organizations included in the Specially Designated Narcotics Traffickers (SDNT) list (US Government)
  • Political parties or movements that have openly and/or systematically promoted violence, human rights abuses or limitations to the UN Charter, UN Declaration of Human Rights, or Geneva Convention
  • Groups which advocate or employ violence and are considered illegal in any of the countries where CISV National Associations are established
  • Any other organization the mission or values of which are contrary to those of CISV

  1. I am not currently declared bankrupt (or similar) or not yet discharged from bankruptcy

  1. I have not been removed as a Charity Trustee or Company Director in accordance with (UK or US) legislation.

  1. I have nohistory of prejudice or intolerance, xenophobia, discrimination, violence or other behaviour contrary to the mission and values of CISV

If you have any comments about any of the above statements, please enter them here.
I have signed this legal document on the date stated immediately below to certify that:
-all of the information I have provided and all of the statements above are true and accurate.
-I consent to CISV International and the CISV International Insurance Company using the information that I have provided, as well as any reference or other form about my application to process my candidature.
Signature of candidate:
Note that this form is not valid without a signature
Date (yyyy/mm/dd):

Thank you for your interest in the CISV International Insurance Company and for providing the above information.

CISV International Ltd
Official Form / (Valid from 2016) / Page 1 of 2