Board Member Application

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone (preferred phone for contact)

Secondary Phone (optional)

Primary Email (preferred email for contact)

Secondary Email (optional)

Place of Employment (if any)

Title at Employment (if any)

Describe your paid or volunteer experience related to services for older adults and family caregivers, or to other related activities or fields.

Describe your leadership experience, including service in the nonprofit sector.

Why do you wish to serve on the Board of Directors?

What are the ways you envision supporting Trellis’ mission?

Upload a biography, resume or curriculum vitae

Max. file size: 512 MB.

As a board member, I acknowledge that I may be subject to background checks required of health care entities including:

US Department of Health & Human Services Office of Inspector General (OIG) List of Excluded Individuals and Entities.
General Services Administration’s (GSA’s) System for Award Management (SAM).
CMS preclusion list (in accordance with CMS requirements and to the extent Delegate is authorized to obtain access to the preclusion list).
Additional site(s) as may be designated from time to time by the OIG, GSA, CMS or other governmental authority.

Further, I understand that I may be asked to provide additional information to Trellis (i.e., the last 4 numbers of my social security number) if needed and requested.

Comments

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