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    Preferred Title*











    Qualifications*

    I, the undersigned, hereby apply to be considered for appointment as a Director of the Corporation, and in doing so, acknowledge and declare that:

    Are you at least 18 years of age?

    Are you a member of the West Nipissing General Hospital Corporation?

    Are you a resident of or carry on business within the area served by the West Nipissing General Hospital Corporation?

    Are you a member of the Professional Staff of the Hospital?

    Are you a current or former employee of the West Nipissing General Hospital?

    Are you the spouse, common-law partner, child, parent, brother, or sister of a member of the Professional Staff who have privileges or of an employee of the Hospital, or any other relationship that would impede your independence of decision making?

    Do you have an undischarged bankruptcy?

    Have you even been convicted of a criminal offence?