CCPM Board - Director Application Form

First Name (Required)

Last Name (Required)

Email (Required)

Phone (Required)

Position of interest (Required)

YesNo

Attestation: I hereby apply to serve as a member of the CCPM Board of Directors. I confirm that I can and will actively support the organization’s mission and the information contained within this application is complete and accurate. I further confirm that I am a CCPM member in good standing. (Required)

Biographical Profile - Please describe in 750 words or less your professional background, volunteer and committee experience as it relates to the Board vacancy you’re interested in, and why you would like to serve on the CCPM Board. (Required)

CCPM Board - Conflict of Interest: Canadian College of Physicists in Medicine ("CCPM") strives to promote the highest standards of public trust and integrity in all of its activities and decision-making and to develop procedures to ensure that the fact or perception of conflict of interest is avoided or effectively managed. The Directors of CCPM have a fiduciary obligation to act solely in the best interests of CCPM in all transactions, decisions, actions, and consultations in which they engage on CCPM's behalf. To avoid conflicts of interest, Directors must do more than merely act within the law. They must conduct their affairs in such a manner that their performance will at all times bear public scrutiny. The appearance of conflict of interest, as well as the conflict itself, must be avoided. The conflict-of-interest report provides the Nominations committee with information to assess candidates’ suitability for the positions of Directors. Potential Directors that are employed by Federal or Provincial governments, or other agencies that have policies limiting their employees’ ability to engage in public discussions are required to disclose any restrictions on their ability to contribute to public discussions relating to the business of CCPM or other public forums that may be of interest to CCPM or its members. Please describe below any relationships, transactions, positions you hold, or circumstances that you believe could contribute to a conflict of interest: (Required)

I have no conflict of interest to report.

I have the following conflict of interest to report...

Conflict disclosure : (please specify other non-profit and for-profit boards you (and your spouse) sit on; any for-profit businesses for which you or an immediate family member are an officer or director, or a majority shareholder; any businesses you or a family member own; and the name of your employer that (potentially) cause conflict of interest): (Optional)

YesNo

I hereby certify that the information set forth above is true and complete to the best of my knowledge. (Required)

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