Board Member Application Form

Thank you for your interest in serving on the Board of Directors for Long Term Care Services of Ventura County, Inc., operator of the Ombudsman Program.

Volunteer board service is a meaningful commitment of time, skills, and resources. As a member, you will help guide strategy, provide oversight, and advocate for the rights and dignity of seniors in long-term care.

Please complete this application to help us learn more about your background, experience, and interests. All applications are reviewed by the Governance Committee within 30 days, and qualified candidates may be invited to interview before being recommended to the full Board for approval.

CONTACT INFORMATION

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Phone

LinkedIn Profile or Website

EDUCATION

Highest Level Completed

High School
College
Advanced Degree

Degree(s) / Field of Study

Name of School

PROFESSIONAL EXPERIENCE

Employment Status

Full-Time
Part-Time
Retired
Other

Current Employer / Organization

Current Position / Title

How many hours per week are you currently working?

Please describe any relevant Employment

VOLUNTEER & FUNDRAISING EXPERIENCE

Please describe your volunteer and community involvement experience.

Please describe any nonprofit or fundraising experience.

Have you served on other nonprofit boards?

Yes
No

What special skills, knowledge, or professional expertise would you bring to the Board?

What do you hope to learn or gain from board service?

Are you willing to support fundraising efforts through personal participation and/or contribution?

Yes
No

FINAL STATEMENTS

Why are you interested in serving on the Board of Directors?

Is there anything else you would like us to know about you?

REFERENCES

Please provide two professional or personal references who can speak to your character and qualifications for board service.

CONFLICT OF INTEREST

Are you an officer, board member, or employee of any organization whose mission overlaps with or competes for the same funding as Long Term Care Services of Ventura County, Inc.?

Yes
No

Do you have any business, family, or personal relationships that might create a conflict of interest with board service?

Yes
No

or same Profile

ACKNOWLEDGEMENT

Before submitting your application, please review the statement below. By checking the box, you acknowledge that the information you have provided is true and complete to the best of your knowledge. You also understand that false or misleading information may disqualify you from consideration for Board service.

Acknowledgement

I certify that the information provided is true and complete.

Board Member Application