INSIGHT
AGREEMENT TO SERVE
Please print or type all information on this form.
Name ________________________________________________________________________
Hospital _______________________________________________________________________
Title __________________________________________________________________________
Address ______________________________________________________________________
Phone ________________ Fax ________________ E-mail ______________________________
INSIGHT POSITION YOU ARE AGREEING TO SERVE ______________________________________
Please list your current or past HBOC user association involvement or activities:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________
Please give us a brief description of your qualifications, talents and potential contributions you would bring to the position if elected:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Some of the positions require a commitment of time and travel to attend Committee, Board and planning meetings. Please make sure that you have the support of your facility and that you consider your ability to meet these commitments.
I HAVE READ THE JOB DESCRIPTION FOR THE POSITION IDENTIFIED ABOVE AND, IF ELECTED, AGREE TO SERVE FOR THE TERM SPECIFIED IN THE INSIGHT BYLAWS.
Candidate’s Signature: ________________________________________ Date: _________
Supervisor’s Signature:____________________________________________ Date: ________
Supervisor’s Name
(please print) _________________________ Title: __________________________Note: If selected as a candidate, this form will be distributed with the ballot to the InSight membership. This will be the only information about candidates distributed.