Board Member Questionnaire Short

Thank you for your interest in serving on the Community Health Centers Board of Directors. Our Board plays an important role in guiding our organization and helping ensure we continue to meet the needs of the patients and communities we serve.

As a Federally Qualified Health Center (FQHC), at least 51% of our Board members must be patients of Community Health Centers. We are committed to maintaining a Board that reflects a diverse range of professional and community perspectives, and we welcome individuals who are passionate about our mission and interested in making a meaningful impact.

Board members are expected to attend monthly evening meetings, typically held on the fourth Thursday of each month.

If you are interested in joining our Board of Directors, please complete the questionnaire below. Each questionnaire will be carefully reviewed, and qualified candidates may be contacted for a personal interview or additional information.

Please note that submitting a questionnaire does not guarantee a seat on the Board. Community Health Centers maintains a pool of qualified individuals interested in Board service, and questionnaire submissions are considered as Board positions become available.

Thank you for your interest in helping shape the future of Community Health Centers.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

No member of the Community Health Centers, Inc. (CHC) Board of Directors shall derive any personal profit or gain, directly or indirectly, by reason of his or her participation with CHC. Each individual shall immediately give written disclosure to CHC of any personal interest which he or she may have in any matter pending before the organization and shall refrain from participation in any decision on such matter. Any member of the CHC's Board of Directors shall refrain from obtaining any list of CHC's clients for personal or private solicitation purposes at any time during the term of their affiliation.

In addition to my potential service to CHC, I am currently a board member or an employee of the following organizations:

Board 1

Board 2

Board 3

Board 4

In order to ensure diversity on our board and answer funder questions, we need the following information. Disclosure is confidential.

Race

Ethnicity

Sex

Why are you interested in joining our Board of Directors?

Board of Directors Questionnaire