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Expression of Interest Submission Form – HSCPOA Board

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EXPRESSION OF INTEREST SUBMISSION FORM RE HEALTH AND SUPPORTIVE CARE PROVIDERS OVERSIGHT AUTHORITY BOARD POSITION  

Call for Expression of Interest

Bylaws

Personal Information

To be eligible for consideration, all Board appointees must fulfill the requirements set out in the Bylaws.

Name(Required)
Address(Required)
(The best number to reach you at)
Email(Required)
Are you a resident of Ontario?(Required)

Board Competencies and Skills:

Please identify the competencies and skills listed below that you possess.(Required)
Max. file size: 16 MB.

Please provide the names and contact information of two (2) references

Reference One

Name(Required)
Phone number for reference one.
Email(Required)
Reference ones relationship to applicant.

Reference Two

Name(Required)
Phone number for reference two.
Email(Required)
Reference twos relationship to applicant.

Declaration:

I hereby declare that the information provided in this application form is true and accurate to the best of my knowledge. I understand that any misrepresentation or omission may result in disqualification from consideration.

Please confirm that you have read the Notice of Expressions of Interest and the (document linked at the top of this form).(Required)
Please confirm that you meet the qualifications for serving on the Board of Directors as set out in Section 5.4 of the bylaws (linked at the top of this form).(Required)
MM slash DD slash YYYY

Please submit your completed form, along with your detailed resume and cover letter.

Thank you for your interest in the Health and Supportive Care Providers Oversight Authority.

For more information about the Health and Supportive Care Providers Oversight Authority, please visit our website at hscpoa.com.

Pursuant to the Personal Information Protection and Electronic Documents Act, the personal information contained in this form will be used solely to assess your qualifications for appointment to the Health and Supportive Care Providers Oversight Authority Board of Directors. Please be advised that you will be required to submit a Criminal Records and Judicial Matters Check should your application move forward.