Board of Directors Application Form General Contact Information:Name Phone Number Email Address Agricultural classification of your operation or workplace? Where is your operation or workplace located? (City & Closest Community) Commodity Association Reference:Please ask your commodity association for a reference to support your application for the board.Association Name: Contact Information: Name Phone Email Permission for AgSafe to contact your reference YesNoAre you eligible?The Society Act says that you can’t be a Director if you fit any one of these categories. Please check any that apply to you. Are less than eighteen (18) years of age.Have been found by any court, in Canada or elsewhere, to be incapable of managing his or her own affairs.Are involved in a bankruptcy which has not been discharged.Have been convicted of fraud or trust related offences.None of the categories apply to me. The AgSafe Board includes four categories of Directors. Do you fall into one or more of these categories? Please check any that apply to you. Are you an owner or operator within one of WorkSafeBC’s agriculture classification units?Are you a farmworker or an individual employed by an organization that represents or supports farmworkers?Are you under the age of forty (40) and involved in agriculture?Do you have an interest or involvement in agriculture or health and safety or employee health and safety?None of the categories apply to me. Do you have previous board experience? YesNo If so, with which organization? What skills or abilities can you bring to help the board to do its work? What would you like to learn as a Director? Do you have any real or potential conflicts of interest? For example, do you make money from an organization that lobbies WorkSafeBC? YesNo Participating on the AgSafe Board requires about 2-4 hours a month, including preparation, Board and Committee meetings. Can you meet this requirement?YesNoTerms of SubmissionBy sending this to AgSafe's Executive Director, you affirm that the information you have provided is true.By sending this to AgSafe's Executive Director, you affirm that AgSafe has permission to contact you directly via the information provided. How will the information you provide be used by the Nomination Committee and AgSafe? AgSafe is subject to legislation that limits how we can use any information we collect, and we will only share information that is relevant to members in the process of electing Directors.