Board of Directors Application

Gardner Health Services always welcomes individuals who are interested in joining our Board of Directors. As a Board member, you can use your skills and talents to help fulfill Gardner’s mission.

"*" indicates required fields

Full Name*

First Name Last Name

Address*

Home Phone Number

Work Phone Number

Mobile Phone Number*

Email Address*

Place of employment or other point of contact*

Do you currently use Gardner’s services?*

Yes

If yes to above question, which health center?

Date you started receiving services from us

Date of most recent appointment

I was referred by

1. I am interested in becoming a Board Member because:*

2. Qualifications and/or qualities that I feel make me a viable Board Member candidate:*

3. Past or present membership in advisory groups, organizations, etc. (list dates):*

Date 1

Date 2

Date 3

4. A. Are you related to any current Board Member by blood or marriage?*

Yes

4. B. Are you related to any current employee of this organization by blood or marriage?*

Yes

5. List 3 references other than family and include their phone numbers with area code. Or, attach 3 letters of recommendation.*

List References

Attach 3 Letters of Recommendation

Reference #1

Full Name*

Address*

Occupation*

Phone*

Reference #2

Full Name*

Address*

Occupation*

Phone*

Reference #3

Full Name*

Address*

Occupation*

Phone*

Attach 3 Recommendation Letters

Attach Recommendation Letters 1-3*

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Experience:

6. List educational background degrees, etc. If available, please upload resume below.*

Upload resume

Drop files here or

Max. file size: 256 MB, Max. files: 2.

Signature*

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Gardner Health Services Corporate Office 160 East Virginia Street, Suite 100 San Jose, California 95112

Info@gfhn.org
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Gardner Family Health Network, Inc. doing business as Gardner Health Services, a 501(c)3 organization, receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. EIN: 94-1743078.

Board of Directors Application

Reference #1

Reference #2

Reference #3

Attach 3 Recommendation Letters

Experience:

GET IN TOUCH

Gardner Health Services Corporate Office 160 East Virginia Street, Suite 100 San Jose, California 95112

MEDICAL RECORDS

NOTICE OF PRIVACY PRACTICES

RELEASE OF INFORMATION

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