Hospice of Montezuma

Name: ______________________________________ Home Phone: ____________________

Home Address: ______________________________________________________________________

Mailing Address: _____________________________________________________________________

Work Address: _______________________________________________________________________

Work Phone: ____________________________ Work Fax: _______________________

E-mail Address: ______________________________________________________________________

Occupation: _________________________________________________________________________

Education/Training: __________________________________________________________________

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What is your experience/understanding of the hospice philosophy? _________________________

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Principal reasons for wanting to serve on the Hospice of Montezuma Board of Directors: ______

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Background, experience that would be of benefit to the Hospice of Montezuma program: ______

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Current or past service on other Boards of Directors: _______________________________________

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Other memberships, volunteer activities: ________________________________________________

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I have specific expertise in the following areas:

___ Strategic/Long-term planning ___ Publicity/Fundraising

___ Public Speaking ___ Finance/Budget

___ Non-Profit Management ___ Hospice Consumer Family

___ Grant Writing ___ Legal/Regulatory

___ Health Care ___ Volunteerism

___ Banking ___ Real Estate

___ Entrepreneurial ___ Problem-Solving

When was the most recent loss you experienced? _____________________________________________

If this was a death, what was your relationship to the deceased? ________________________________

How many hours per week can you devote to board membership for Hospice of Montezuma? _____

Are you willing to make a 2 or 3-year commitment to the Board of Hospice of Montezuma? ________

Prospective Board Members will be selected to fill vacancies without regard to race, color, religion, sex, national origin or marital status.