EmailMe Form - BOARD OF DIRECTORS NOMINATION NOTIFICATION

Name of Member Making Nomination:

First Last

Name of Nominee:

First Last

LPCHS Membership Class:

Email

Mobile Phone

### - ### - ####

Residence Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Are you at least 21 years of age?

Please Check Yes or No

Occupation/Employment:

Does the nominee have any felony conviction (including guilty or no contest) within twenty years prior to the date of this application?

Please Check Yes or No

Does the nominee have any convictions for any offense involving animal abuse or domestic violence?

Please Check Yes or No

Is the nominee or their spouse, a shareholder, voting member, or employee of a competing business interest?

Please Check Yes or No

Does the nominee have any misdemeanor conviction involving elements of fraud, concealment, misrepresentation or theft by deception within ten years prior to the date of this application?

Please Check Yes or No

Does the nominee have an immediate family member who is an employee of the La Plata County Humane Society? (The term “immediate family member” means a spouse, father, stepfather, mother, stepmother, daughter, stepdaughter, son, stepson, sister, stepsister, half-sister, brother, stepbrother, half-brother, father-in-law, mother-in-law, daughter-in-law, son-in-law, grandfather, grandmother, grandchild, and first cousin.)

Please Check Yes or No

If you answered “Yes” please describe the contrary position in detail:

Has the nominee ever taken a position contrary to the interests of the La Plata County Humane Society, as those interests are defined by its Bylaws, the Articles of Incorporation, or the Mission Statement?

Please Check Yes or No

Does the nominee have any conflict of interest of any kind, including financial conflicts of interest with the La Plata County Humane Society?

Please Check Yes or No

If you answered “Yes” please describe the contrary position in detail:

Does the nominee agree to support all the purposes and policies of the La Plata County Humane Society which state as follows:

The purposes of the La Plata County Humane Society (Society) are the prevention of cruelty to animals, the relief of suffering among animals, and the extension of humane education. The Society provides humane care and treatment for all animals needing protection in the areas served by the Society; seeks to return lost animals to their owners; seeks suitable homes for animals without owners; and provides euthanasia, when necessary. In its care of animals, the Society shall make reasonable efforts to meet the minimum standards prescribed by the various national humane organizations.

Please Check Yes or No

Signature

Clear

Date Time

MM / DD / YYYY

* Nominee: Please submit this form with a letter stating your interest by the designated closing date of 3/15/23 to cassidy@lpchumanesociety.org or call (970) 259-2847 x108 to drop off in person.