CMH Board/Committee Member Application Survey - 2019 cv

Thank you for your interest in applying to becoming a member of the CMH Board or one of the CMH Board committees. This survey is used to gather information on all candidates. In addition to completing this survey, please send a resume to Cheryl Vandervalk at cvandervalk@cmh.org. Cheryl's email also appears at the end of this survey and is on the CMH website. www.cmh.org

Please answer each of these questions.

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* 1. Please provide your name

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* 2. Please provide contact information

Email address: *

Home phone number: *

Mobile phone number

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* 3. Are you at least 18 years of age?

Yes

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* 4. Are you an employee of CMH?

Yes

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* 5. Are you a member of the professional staff at CMH?

Yes

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* 6. Are you an "undischarged bankrupt"? (meaning - are you a bankrupt person who has not been granted an order of discharge by the court?)

Yes

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* 7. Do you live in Waterloo Region?

Yes

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* 8. Do you work in Waterloo Region?

Yes

Other

If "Other". please describe

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* 9. Have you been convicted of a criminal offence?

Yes

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* 10. In the preceding 5 years, have you been found guilty of a non-criminal offence that relates to financial dishonesty or are otherwise relevant to the operation of a charity, including violations of fundraising, consumer protection or securities legislation)?

Yes

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* 11. In the preceding 5 years, have you been a director of a charity during a period in which the charity engaged in conduct that was a serious breach of the requirements for registration for which the charity had its registration revoked?

Yes

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* 12. In the preceding 5 years, have you been a promoter of a gifting arrangement or other tax shelter in which a charity participated and the registration of the charity has been revoked?

Yes