EmailMe Form - LHC Board of Directors & Committee Application '25

Name *

First Last

Home Phone

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

Mobile Phone *

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

Email *

Do you live or work in London, ON? *

Yes

No

Address *

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

Area of Interest *

Board of Directors

Committee: Finance

Committee: Governance|Nominating

Committee: CHIP Review Panel

Portfolio Website

Upload Your Resume *

Word or PDF Documents Only

Cover Letter: Please highlight the specific skillsets you bring to the organization and how these can be beneficial. *

Date Time

MM / DD / YYYY