North Mississippi Primary Health Care, Inc. Board Member Application

Thank you for your interest in applying to become a voluntary member on the Board of Directors for North Mississippi Primary Health Care, Inc. North Mississippi Primary Health Care, Inc. is a non-profit organization and a co-recipient of a grant from the federal government which allows it to operate as a Federally Qualified Health Center (FQHC).

FQHCs are non-profit or public entities that serve designated medically under-served populations. To qualify as a FQHC, North Mississippi Primary Health Care, Inc. must meet certain requirements. The following application requests personal information related to your role as a prospective Board member, including information specifically related to the FQHC requirements.

PERSONAL INFORMATION

Name:(Required)

First Middle Last

Address(Required)

Street Address: City: Zip:

County:(Required)

Email:(Required)

Email Address Confirm Email Address

Telephone:(Required)

Gender:

Male

Female

Transgender Male / Female-to-Male

Transgender Female / Male-to-Female

Decline to Answer

Other (please state)

Are you at least 18 years of age?(Required)

Yes

Race:

American Indian or Alaskan Native

Native Hawaiian or other Pacific Islander

More than One Race

Black or African-American

Asian

Non-Hispanic / Latino

White

Decline to Answer

Ethnicity:(Required)

Hispanic / Latino

Non-Hispanic / Latino

Decline to Answer

EMPLOYER INFORMATION (if applicable):

FQHCs cannot have more than half of their non-patient board members receive income that exceeds 10% of their annual income from the healthcare industry.

Are you currently employed in the health care industry? (if uncertain please select Yes, and we will work with you to make a determination.)(Required)

Yes

Is greater than 10% of board member's income from the Health Industry?(Required)

Yes

Employer:

Area of Expertise:

QUALIFICATIONS

As an FQHC, North Mississippi Primary Health Care, Inc. board of directors is required to have at least 51% patient representation. Someone who is the parent of a NMPHC patient or who is financially responsible for someone who uses our services may qualify for the position providing patient representation.

No Board member may be an employee of North Mississippi Health Care, Inc. or an immediate relative of an employee, including a spouse, parent, child, or sibling through blood, adoption, or marriage.

Are you or a direct family member currently a NMPHC patient or are you financially responsible for someone who is a NMPHC patient?(Required)

Yes

Please select particular interests or specialty knowledge:

Community Affairs

Finance / Banking

Legal

Government

Leadership / Strategic Planning

Business Management

Real Estate

Other (please state)

BOARD MEETINGS

Regular Board meetings are currently held monthly on the third Monday of each month at 6:00 p.m. Meeting attendance is necessary for the Board to function cohesively and to be effectively informed. Although in-person participation is preferable, arrangements are made for telephone participation.

Are you able to attend monthly meetings?(Required)

Yes

Please select any accommodations you may require:

Visual

Hearing

Mobility

Cognitive

Childcare

Transportation

Other (please state)

STATEMENT OF INTEREST

Why are you interested in serving on North Mississippi Primary Health Care, Inc. Board of Directors?(Required)

I certify the information given in this application is true and complete to the best of my knowledge.

Please note acceptance on North Mississippi Primary Health Care, Inc. of Directors is contingent upon the successful completion and clearance of a criminal background check and the Office of Inspector General’s exclusions check.

Signature(Required)

Date(Required)

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Name

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