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3 <br /> ■ <br /> '� ��� Please return application and <br /> supporting documents to: <br /> Health Alliance Health <br /> Attn:Veronica Ingram, Clerk to the Board <br /> 5200 W. Paramount Pkwy, Ste. 200 <br /> BOARD MEMBERSHIP APPLICATION Morrisville, NC 27560 <br /> (Application must be signed before submitting. All or sign, scan and submit electronically <br /> information on this document will be released to the with supporting documents to <br /> public upon request.) Vingram@A]IianceHeaithPlan.org. <br /> Contact Information <br /> Name: 4 i t L►Atl C . ✓ozo pL; A4D) M PH <br /> Primary Phone Number: q /1 7- 3— 3 9 0 7 <br /> r,r-Go µ <br /> Primary Email Address: J%A bs'Q <br /> j, N►e1� h . <br /> Street Address: ,S^D 6 Sr'vvi✓ <br /> City-4;11S'6�'°�',��' County: OvP-06-J'a— State: NC zip: 2-1 til <br /> Eligibility to Serve <br /> The Alliance Board holds regular monthly meetings. Some meetings take place at one of the community <br /> offices; otherwise, meetings occur at the home office in Morrisville. Board members participate on 2-3 <br /> subcommittees based on their expertise and interests. Most Board members dedicate between 6-10 hours <br /> per month on Board activities, more if they choose to serve on special projects. <br /> Candidates for Board membership must be residents from one of the counties served by Alliance. <br /> Employees, family members of employees, or volunteers of provider agencies or vendors contracted with <br /> Alliance, or persons with a financial interest or ownership in any such agency or vendor, are not eligible to <br /> serve. <br /> While Board members are appointed because they represent a certain community, once on the Board, their <br /> responsibility is to all individuals served by Alliance. <br /> Are you a provider that has a contract or referral relationship with Alliance or do you work for or serve on a <br /> board of a provider that has a contract or referral relationship with Alliance? If so, please provide the name of <br /> the provider and your role. <br /> Do you have a contract with another LME/MCO? If so, please explain. IVC7 <br /> Are you a Lobbyist under Chapter 120C of the General Statutes? If so, under what capacity? No <br /> Rvsd 12/2/2021 <br />