Part 1: General Information

Name

First Name

Last Name

Work Address

Street Number

Street Name

Town/city

Province

Postal Code

Phone

Work

Home

Mobile

Email

Personal

Business

Resume or Curriculum Vitae

Part 2: Eligibility Criteria

1. Are you a member in good standing of your Provincial Chiropractic Association?
YesNo

2. Are you a member in good standing of the Canadian Chiropractic Association?
YesNo

3. Are you the subject of any disciplinary or regulatory proceeding?
YesNo

4. Do you have any potential conflicts of interest with respect to this committee (i.e., currently serving as a member of another research group)?
YesNo

5. Are you aware of any issues which may prevent you from serving as an effective member of this committee?
YesNo

If you answered “Yes” to questions 3, 4 or 5. please provide further information (2400 characters)

Part 3: Core Competencies

1. Think of a time where you had to represent the best interests of one professional group ahead of another. How did you make your decision? How did you communicate your perspective to others? (2400 characters)

2. Describe what “consensus decision-making” means to you? How do you think this type of decision-making would be beneficial for this committee? (2400 characters)

3. Imagine you must decide to fund only one project when you’ve been presented with three good proposals. What tools or techniques would you use to decide? (2400 characters)

4. Consider a time where you made a commitment to a team task but then became overwhelmed with work or personal obligations. What did you do? (2400 characters)

5. Please write a paragraph summarizing what you see as the main priorities for chiropractic research in Canada over the next five years. (2400 characters)

Signature of Applicant (Electronic entry of name is acceptable):

Date:

Committees depend upon the input and active participation of their members. Applicants should note that regular attendance at committee meetings is an expectation.

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