HR Board Member Affirmation Statement

HR Board Member Affirmation Statement

I. Appointment and Identification

Organization Name:

II. Board Position and Term

Position/Title:

Committee Assignment(s):

Term Start:     Term End:

III. Employment History (Most Recent)

IV. Education

V. Professional References

Please provide three professional references.

VI. Conflicts of Interest; Disclosures

Please respond to each item below and provide details where requested.

I have no actual or perceived conflicts of interest with the Organization that would impair my objectivity.

I or a close family member hold a financial interest in, or employment/consulting relationship with, a supplier, competitor, or contractor of the Organization.

Other possible conflicts exist (describe below).

VII. Legal Disclosures and Authorizations

By signing this Affirmation Statement I certify that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that making false statements or omitting material information may subject me to removal from the board or other administrative or legal action.

Equal Opportunity: The Organization is committed to equal opportunity in board appointments and does not unlawfully discriminate in appointments on the basis of race, color, religion, sex, national origin, age, disability, or other protected characteristics.

At-Will Statement: If a board appointment is concurrent with an employment relationship, such employment (unless governed by a separate written agreement) is at-will and may be terminated by either party at any time. This statement does not create any contractual employment right unless specifically set forth in a separate, signed employment agreement.

Background Check Authorization: I authorize the Organization and its agents to obtain and verify information about my background, including criminal history, civil litigation records, education, employment history, and references. I understand that the results of such checks may be used to determine my eligibility for appointment or continued service.

I authorize background checks and release the Organization and any third parties from liability for information obtained in good faith.

No    Yes — If yes, provide details below.

VIII. Conduct, Confidentiality, and Recusal

Confidentiality: I acknowledge that I may receive confidential, proprietary or personally identifiable information in my capacity as a board member. I agree to maintain the confidentiality of such information, to use it only for authorized board purposes, and to comply with all applicable confidentiality and data protection policies of the Organization.

Recusal: I agree to recuse myself from discussion or voting on any matter where my impartiality may reasonably be questioned due to a personal, financial, familial, or other relationship. I will promptly disclose the nature of any potential conflicts and will follow Organization policies regarding recusal.

Compliance: I agree to comply with applicable laws, the Organization's bylaws, governance policies, and the standards of conduct established by the Organization for board members.

IX. Applicant Certification and Authorization to Contact

I certify under penalty of perjury that the statements contained in this Affirmation Statement are true and complete. I authorize the Organization, its agents, and its authorized representatives to contact the employers, educational institutions, references, and other entities identified in this form to verify information and obtain additional information necessary to evaluate my suitability for board service.

I understand that the Organization may make such inquiries as necessary and that information provided may be used in determining my appointment and continued service. I release all parties from liability for providing information in good faith.

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