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* 1. Name

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* 2. Email address

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* 3. Home address

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* 4. Work address

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* 5. Who do you currently work for? (Include organisation and position, if employed; include main clients if self-employed)

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* 6. Please indicate whether you fulfil at least one of the following criteria

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* 7. Previous experience (Please list up to the four most recent boards and/or committees that you serve on, or have served on.)

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* 8. Your skills and experience (please tick at least 2)

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* 9. How do you feel HJN would benefit from your membership on the Supervisory Board? (Min. 100 words)

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* 10. Please provide links to your personal and/or organisational websites and/or LinkedIn profile.

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* 11. Anything else you’d like to tell us?

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* 12. Please provide the name, organisation (if applicable) and email address of two references. Please note that your references will only be contacted if you are shortlisted.

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