Oakland Community Health Network Board

Oakland County Board of Commissioners

Oakland County Board of Commissioners

Application For Appointment To 

The Oakland Community Health Network Board

Note: Please complete this application form in its entirety. Should this application form not be fully completed, or contain false or misleading information, the Board of Commissioners reserves the right to reject the application or terminate the appointment. Information included in this application is subject to the Michigan Freedom of Information Act. All applicants may, at the County’s discretion, be subject to a security check and clearance. All qualified applicants receive consideration for appointment without regard to race, color, sex, age, disability, national origin, religion, genetic information, political affiliation, marital status, height, weight, arrest record, sexual orientation and/or any other reason in accordance with applicable state and federal laws. 

In order to be eligible for application, you must be at least 18 years of age, a U.S. citizen and a resident of Oakland County.
     
Please Provide Information for your Home/Legal Residence










  
You are ineligible to apply if:
  • You have been previously excluded from participation in a Federal health care program, including Medicare and Medicaid pursuant to 42 C.F.R. § 438.610.
  • You are currently employed by the Michigan Department of Community Health or the Oakland Community Health Network.
  • You are a party to a contract with the Oakland Community Health Network or administering or benefiting financially from a contract with the Oakland Community Health Network.
  • You serve in a policy-making position with an agency under contract with the Oakland Community Health Network.













 
 
Education






 
 
Employment
Please list your most recent work experience first, including full-time, part-time and volunteer work. You may also upload a copy of your resume or any documentation that supports your employment history.






 

If you would like to mail or fax documents, see our contact page for address and fax number.

 
 
References





I affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge.  I understand that falsified information or omissions may disqualify me from further consideration for appointment and may be considered justification for removal if discovered at a later date. 

I authorize an Oakland County representative to contact individuals or organizations listed as references or previous employers on this application. Additionally, I authorize a search of the Office of Inspector General’s exclusions database to ensure I have not been excluded from participating in any federal health care programs.

I understand that typing my name in the signature box below creates an electronic signature that has the same validity as actually signing the form and either faxing it back or mailing it back via the U.S. Postal Service.