PVHCD – Measure N Independent Citizens’ Bond Oversight Committee Application Form

PVHCD > PVHCD – Measure N Independent Citizens’ Bond Oversight Committee Application Form

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Full Name

Street

City

State

Zip

Phone

Current Employment

Current Job Title

What do you know about Measure N and Pajaro Valley Health Care District (the “District”):

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What other Boards / Commissions / Committees / Groups are you currently serving on:

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Please state why you would like to serve on the Bond Oversight Committee for Pajaro Valley Health Care District (the “District”):

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Please list relevant experience to serve as a member of the Bond Oversight Committee:

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Are you a current employee of Watsonville Community Hospital, Coastal Healthcare, or the Pajaro Valley Health Care District?

YesNo

Are you a former employee of Watsonville Community Hospital, Coastal Healthcare, or the Pajaro Valley Health Care District?

YesNo

Are you a current clinician who provides services at Watsonville Community Hospital?

YesNo

Do you have a family member who is an employee of Watsonville Community Hospital, Coastal Healthcare, or the Pajaro Valley Health Care District

YesNo

Are you a vendor, contractor, or consultant to Watsonville Community Hospital, Coastal Healthcare, or the Pajaro Valley Health Care District?

YesNo

Do you understand the roles and responsibilities of the Oversight Committee?

YesNo

Will you comply with the Committee Bylaws?

YesNo

Do you have any conflicts that would preclude you from attending Committee meetings?

YesNo

Do you know any reason, such as a potential conflict of interests, which would adversely affect your ability to serve on the Committee?

YesNo

NOTE: When sending this application form, I certify that I have answered this form truthfully and to the best of my knowledge.

The agenda for this meeting has not yet been prepared. Please check back 72 hours prior to the start of this meeting.