2014 NHPCO Committee Service Application

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NHPCO Committee Service Application

Name:

E-mail:

Phone:

Academic Degrees or Certifications:

Committee Applied For:

(Professional Education, Public Policy, Quality Standards, Regulatory)

Member Affiliation

Committee members must be affiliated with a current NHPCO member. NHPCO membership information is available at www.nhpco.org or by calling NHPCO’s solutions center at 800/646-6460.

Indicate how you satisfy the membership eligibility criteria.

I am affiliated with a:

Provider Member* Associate Member State Organization Member

Member Organization:

Address:

City: State: Zip Code:

Describe your affiliation with the member.

Staff member, list job title:

Volunteer, describe role:

Board member

* Individuals employed by a hospice or palliative care provider must meet the membership eligibility requirement based on the membership status of their employer. Other, non-employment affiliations with an NHPCO member organization may not be substituted for an employment relationship with a non-member hospice or palliative care provider organization.

Organizational Approval

NHPCO asks committee applicants to review the expectations of committee service with their employer and secure the employer’s support for active participation in the committee

By submitting this application, you certify that you reviewed the expectations of service with your supervisor or other appropriate person with your employer (President/CEO, Board Chair, Executive Director, etc.) and they agreed to support your active participation in this committee.

Supervisor’s Name and Title:

E-mail: Phone:

1.  What expertise or experience will you bring to the committee?

2.  Please list prior NHPCO committee service, include dates of service.

3.  Have you served on a state hospice and palliative care organization’s committee? If yes, please briefly describe the committee and note the length of your service. Make sure to include the name of the state organization.

4.  Other comments you’d like to share

Please return this document to NHPCO no later than October 31, 2014.

E-mail: or

NHPCO

Attn: 2014 Committee Service Application

1731 King Street

Alexandria, VA 22314

1731 King Street, Suite 100 • Alexandria, Virginia 22314

703/837-1500 • 703/837/1233 (fax) • www.nhpco.org