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Home Assist Community Services

133 Adelaide Street Maryborough 07/4123 2234

07 4123 2234

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Board of Directors Nomination Form

Form Reference Number 16

Personal Information

First Name *

Last Name *

Date *

Your Email *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone Number

Home Phone

Birth Date *

Nationality

Business Information

Title / Profession *

Company / Organisation *

Your Email

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Work Phone

Extension

Please list your current and past Board experiences, if applicable

What are your current associations and/or club affiliations (include titles if possible)

Please list your skills and expertise

Please describe in details some of your greatest strengths and weaknesses

What do you feel is essential to ensure that the Board and staff are successful in attaining the goals for this organization?

Please detail your interest in joining this Board

What type of Board tasks do you prefer?

Tick the areas of interestBoard Building & GovernanceFinance & Human ResourcesDevelopmentFinanceOther

Thank you for your interest. I certify that my signature confirms that I will adhere to the code of conduct . *

Start signing your signature here

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Home Assist Community Services

- Work For Us -

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845
Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)

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