PAN Board Application

In accordance with the information on our website

1. APPLICANT DETAILS

Name(Required)

First Last

My pronouns are

Residential Address (for Annual Report and charity return):(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Date of Birth (for charity return):(Required)

Please review this section of the BC Societies Act before continuing.

I confirm that I am able to serve under the Societies Act(Required)

Yes

I wish to be considered for appointment, or to run for the Board of Directors at PAN, under the rules of Bylaw 50, as a regional representative AND/OR a person with lived/living experience (PWLLE) (tick one box in each section):

REGIONAL(Required)

Provincial (PHSA)

Provincial (FNHA/Indigenous voice)

Northern

Interior

Fraser

Vancouver Coastal

Vancouver Island

NOT REPRESENTING A REGION

PWLLE Status(Required)

Person living with HIV (PLHIV)

Person with lived/living experience of hepatitis C

PLHIV with lived/living experience of hepatitis C

NO lived experience of HIV or hepatitis C

2. PAN MEMBER ORGANIZATION ENDORSEMENT OF APPLICATION

In order to join the PAN board of directors, you have to be associated with a PAN member organization. One of PAN’s expectations of our members states “Recommend candidates for the PAN Board of Directors and support their engagement at the board level (particularly for PWLLE).”

I am an authorized representative of the following PAN member organization:(Required)

I am attaching a written endorsement from the PAN Member organization:(Required)

Yes

If yes, upload endorsement.

Max. file size: 49 MB.

If you don't upload an endorsement, we will contact the PAN Member organization. Please supply the details of the staff member or volunteer (Executive Director, Program Manager, Board Chair or equivalent) who can confirm the support of the PAN member organization:

First Last

Phone

I confirm that the organization has committed to support my engagement:(Required)

Yes

Much of the work of the PAN board happens virtually. I have access to a computer and internet for all meetings and preparation:(Required)

Yes

3. SUMMARY OF INTEREST, QUALIFICATIONS AND/OR EXPERIENCE

I am attaching a written statement or resume that highlights my HIV, hepatitis C and related volunteer and/or work experience or other relevant background, education and training (i.e. Positive Leadership Development Institute):(Required)

Max. file size: 49 MB.

IF not already captured in the written statement, above, please tell us about your interest in becoming a PAN Board member, including how you feel you would contribute to the work of the Board.

I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief.(Required)

First Last

Date(Required)

Once you have filled out this form, please press the SUBMIT button. If all the required sections are complete, you will be taken to a thank you page. If you aren't taken to a thank you page, some information is missing on this form.