Application for the Board of Directors of Mosaic and the Mosaic Foundation

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Nominee's Preferred E-mail

Age

Gender

Race/Ethnicity

Religious Preference: As a recognized and affiliated organization of the Evangelical Lutheran Church in America (ELCA), a majority of Board members must be Lutheran. Please share the nominee's religious preference.

Mosaic is committed to ensuring that our boards of directors represent the communities we serve. In this space, please share any information that will help us understand how the nominee's appointment will help Mosaic better represent the diverse disability community. Dimensions of diversity include: race, ethnicity, gender identity, sexual orientation, disability, education, religion/spirituality, country of origin, tribal community, languages spoken, socio-economic status and military service. Your response is entirely voluntary.

Please Identify the nominee's connection, if any, to the I/DD Community.

Mosaic is primarily funded by Medicaid and background checks are completed on all prospective board members to ensure compliance with all local, state and federal funding requirements. These background checks may include, but are not limited to:

Criminal History for the Last Seven Years (except where state requirements differ);
Abuse/Neglect Registry;
State Sex Offender Regristy;
National Sex Offender Regristy;
Confirmation of Licensure Status or Certification;
Credit;
Education Verification;
Reference Checks;
Motor Vehicle Record;
E-Verify;
HHS/OIG List of Excluded Individuals and Entities (LEIE);
General Services Administration’s System for Award Management (SAM);
State Medicaid Exclusion Lists

Mosaic maintains an account with a third party vendor to complete background checks (not including reference checks) where allowed by state regulation. Background checks are conducted by national supports office staff and results are provided to the Mosaic Board's Executive Secretary.

Professional Experience

Please share additional information about your professional experience:

Industry Knowledge

Please share additional information about your industry knowledge:

Does the nominee have any history with Mosaic or its predecessor organizations: Bethphage and Martin Luther Homes? If so, please share:

Does the nominee have any significant connections with the following attributes, individuals or groups?

Please explain any connections:

Please list the nominee's current and past board or committee experience.

Please list any other relevant volunteer or professional experience.

Please note if you are filling out this form on your own behalf or if you are nominating another individual:

Why are you interested in serving on a board for Mosaic?

What unique skills, ideas and connections will you bring to Mosaic?

From your perspective, what are the top three issues that Mosaic should be focusing on right now and or in the future?

Please list three references (including contact information) who know you and your professional experience well:

Upload Resume or CV:

Upload a File

Your LinkedIn Account:

Your Name:

First NameLast Name

Your E-mail:

Your Phone Number

Area CodePhone Number

Your relationship to the nominee:

Why do you believe the person you are nominating is a good fit for Mosaic?

What unique skills, ideas and connections will they bring to Mosaic?

Nomination Application for the Board of Directors of Mosaic and the Mosaic Foundation

Nominee's Information

Experience