Dear Board of Directors Candidate:

Dear Board of Directors Candidate: On behalf of the 2015 Nominations Task Force, thank you for your interest in applying as a candidate for election to the Board of Directors of the National Certification Board for Therapeutic Massage & Bodywork. We have compiled a complete application packet with all of the information and tools you will need for its completion. This year certificants will elect one practitioner member to the Board of Directors; the term of the position is four years, beginning with the Board s annual meeting in 2016. Criteria and Qualifications for Practitioner Member of the Board To be considered for a Board position, an applicant must: Be Board Certified by NCBTMB; or, if Nationally Certified, must transition into Board Certification by January 1, 2016. Have a minimum of five years experience in the profession of therapeutic massage and/or bodywork. Agree to abide by NCBTMB's Conflict of Interest Policy, Code of Conduct for Volunteers, and other agreements included in this candidate application packet. Commit to the time and travel necessary to be a fully participating member of the Board, including attendance at meetings, serving as a liaison to committees, and travel on behalf of the Board. In addition, no Director can hold a national level office in another competing therapeutic massage and/or bodywork professional or trade organization. Consideration will be given to knowledge, skills and experience that are necessary for functioning on the NCBTMB Board of Directors. Familiarity with organizational structure and the roles and responsibilities of a Board of Directors, both as a Board and as individual Directors, is useful. The ability to participate in a decision-making process including supporting decisions once reached is important. An understanding of the role of a certification body within the profession as well as a broad view of the profession itself is useful. Therefore, previous board membership and non-profit organization experience, including previous NCBTMB volunteer experience, will be given weight in the deliberations of the Nominations Task Force. Application Forms and Supporting Documents The Board of Directors Candidate Application consists of 9 documents: 7 forms, your essay, and your resumé. We have provided a checklist and submission instructions for your reference. Please note that only complete applications received by the June 30, 2015 deadline will be processed. Please also be aware that multiple pages of the application require a signature. The Application Process Once completed applications are received, they will be reviewed by the Nominations Task Force. The selected candidates will be scheduled for telephone interviews by members of the Nominations Task Force. Based on the applications and the interviews, candidates will be slated for the election ballot. Slated candidates will be required to submit information for the ballot and election packet. All certificants in good standing as of July 31, 2015 will be invited and encouraged to vote in the election for the new member to the Board of Directors. Important Dates All completed applications must be received no later than June 30, 2015 by 5:00pm Central Daylight Time. Selected applicants will be interviewed by members of the Nominations Task Force between July 2, 2015 and July 22, 2015. All applicants must be available for a telephone interview during this time period. The slate of candidates that will appear on the ballot will be finalized prior to July 24, 2015. Voting is scheduled to be completed no later than September 17, 2015. The newly elected Board member takes office at the Board s Annual Meeting, which will take place early in 2016. Thank you again for your interest in standing for election in this important capacity. The Nominations Task Force looks forward to reviewing your application. Best Regards, Leslie Suzy Ko 2015 NCBTMB Nominations Task Force Chair 1

Name: NCBTMB Board of Directors Candidate Application Checklist Please review, complete, and sign the following documents: Board of Directors Candidate Application for Volunteer Leadership Conflict-of-Interest Policy and Form Confidentiality and Nondisclosure Agreement Code of Conduct for Volunteers Policies and Procedures Form Time and Travel Commitment Form Attestment to No Criminal Activity Form Please attach the following documents: Essay (one typed page): Why do I want to be a member of the NCBTMB Board of Directors? Resume: Please detail educational qualifications, skills, and professional activities Once finished, your application will have a total of nine (9) different documents. PLEASE NOTE: only completed applications that are emailed, received by U.S. mail or faxed to the NCBTMB office by 5 PM Central Daylight Time on Tuesday, June 30, 2015 will be processed. If you have any questions, please call 630-652-0454. To submit your application, please select one of the following methods: Email directly to mhrach@ncbtmb.org (must be received by 5:00 pm CDT on June 30, 2015) Mail (must be received by 5:00 pm CDT on June 30, 2015): NCBTMB Nominations Task Force 1333 Burr Ridge Parkway, Suite 200, Burr Ridge, IL 60527 Fax directly to 866-511-2805 (must be received by 5:00 pm CDT on June 30, 2015) 2

NCBTMB Board of Directors Candidate Application for Volunteer Leadership Please complete all forms and checklist items and return as follows: Email your completed application packet to mhrach@ncbtmb.org, fax directly to 866-511-2805, or send via regular mail to NCBTMB Nominations Task Force, 1333 Burr Ridge Parkway, Suite 200, Burr Ridge, IL 60527. Name: NCBTMB Cert. # Cert. Date: Address: City: State: Zip: E-mail address: Primary phone: Secondary phone: Fax: I. Certification Status When did you become Nationally Certified? What is your recertification date? Do you plan to recertify? (yes / no) I understand that remaining in good standing with NCBTMB is required, including maintaining national certification and that failure to do so may result in removal from the Board. (please initial) II. General Education: Please mark highest level attained and indicate major area of study. High School (or equivalent) Technical / Vocational Certificate College Degree (2 year) College Degree (4 year) Master s Degree Doctorate Special Training / Certifications Other Major area of study: III. Experience in Massage/Bodywork Number of years in practice Not practicing massage therapy/bodywork Other Occupation: Currently practicing: Full-time (75% + of income) Part-time (<50% of income) Please mark all that apply to your work setting: Private practice in clinic or office Corporate on-site Private practice in home Chiropractor s office Hospital, nursing home or hospice Osteopath s office Spa, medi-spa Physical therapy office 3

Fitness center or health club Group practice rehabilitation Sports medicine facility Group practice primary care Holistic health center Education / Training Resort, hotel, cruise ship Beauty salon Other (please describe) IV. Communication Are you computer literate? (yes / no) If not, are you willing to learn and obtain the necessary equipment? (yes / no) Are you available by e-mail daily? (yes / no) V. Organizational Experience (Feel free to utilize additional sheets as needed) Teamwork: 1. What organizations have you volunteered for and in what capacity did you volunteer? 2. Have you served on a national, state or local board or committee? What was your role? Was this a volunteer or paid position? 3. Do you currently hold a national (elected) office in another therapeutic massage and/or bodywork professional or trade organization? If so, will you relinquish this position if elected? 4. Describe your experience as a team member. How did you contribute to the group? What was your role? 4

5. Due to the size of the NCBTMB Board of Directors and the length of the term, chances are that you will be called upon to serve as the Chair or a member of the Executive Committee (EC). What experiences and qualities do you possess that qualify you as Chair of the Board / EC member? 6. What special talents do you have to bring to the Board? 7. If you were the only one or part of a small minority in favor of an action at a Board of Directors meeting and a large majority of the Board had a different opinion, how would you approach this situation? 8. Give an example of a vision or goal you had that you were able to manifest. Indicate your experience with strategic planning (Please mark all that apply) Facilitated strategic planning activities Assisted with facilitations Developed a strategic plan as part of a group Served on a planning committee Worked with a strategic plan Other: (please describe) Presentation skills (Please mark all that apply and name the group(s) and date(s) / location(s) where applicable) Have presented before a national group: (please describe) 5

Have presented before local group: (please describe) Have been a keynote speaker name of event: Have been on television or other media Have taught Other: (please describe) Indicate your experience with organizational budgeting (Please mark all that apply) Developed a budget for a group Presented a budget before a group Worked on a budget with a group Can interpret a spreadsheet Kept the books for an organization Other: (please describe) Would you be willing to serve on a committee/subcommittee/task force/panel if not nominated? Yes No VI. Issues: Identify three issues you see as impacting certification in the massage therapy / bodywork profession in the next three to five years. VII. References Please provide the name and contact information, including phone and email if applicable, for three or four personal / professional references. 1. 2. 3. 4. VIII. Statement of Understanding I understand that the information provided in this application packet is subject to verification and further discussion during the Board of Directors nominations process. Statements made are true. Name Signature Date 6

NCBTMB Conflict-of-Interest Policy and Procedure (As Revised May 15, 2008) I. Statement of General Policy The purpose of this Conflict of Interest Policy & Procedure ( Policy ) is to protect the interests of the National Certification Board for Therapeutic Massage & Bodywork, Inc. ( NCBTMB ) by avoiding conflicts of interests by NCBTMB volunteers and persons compensated by NCBTMB. Conflicts of Interests are undesirable because they may or do place the interests of others ahead of NCBTMB s obligations to its stakeholders and to the general public. Therefore, this Policy requires that all volunteers and persons compensated by NCBTMB who have actual or apparent conflicts of interest must disclose such actual or apparent conflicts of interests promptly and fully to all necessary parties, as set forth below, in order for NCBTMB to determine whether such conduct violates this Policy and should be prohibited. A. Definitions The following terms, when used herein, shall have the meanings set forth below: 1. Interested Person Any person working with or for NCBTMB, whether compensated by NCBTMB or as a volunteer, who has a direct or indirect Financial Interest, Influence Interest, or Competitive Interest, all as defined below, is an Interested Person. If a person is an Interested Person with respect to any part of an entity, he or she is an Interested Person with respect to the entire entity. 2. Financial Interest A person has a Financial Interest in any entity if the person has, directly or indirectly, an ownership or investment interest, a compensation arrangement, or a potential ownership or investment interest in, or compensation arrangement with, such an entity. 3. Influence Interest A person has an Influence Interest in any entity if the person is a director or officer with such an entity or if the person has a friendship or family relationship with such an entity. 4. Competitive Interest A person working with or for NCBTMB, whether compensated by NCBTMB or as a volunteer, has a Competitive Interest in a situation or circumstance when such person may or will gain a competitive and/or economic advantage resulting from NCBTMB s involvement or lack of involvement with another person or entity. 5. Conflict of Interest A Conflict of Interest occurs when an Interested Person has a Financial Interest, an Influence Interest or a Competitive Interest. The NCBTMB Board of Directors ( Board ) shall determine whether such Conflict of Interest is of such a nature so as to make it unlikely, or apparently unlikely, that the NCBTMB volunteer or persons compensated by NCBTMB can act independently and objectively in the best interests of NCBTMB. 7

B. Coverage of the Policy This Policy shall apply to any person working with or for NCBTMB, whether compensated or volunteer, including independent contractor providers of services and materials. C. Procedures Under the Policy The following procedures shall apply to all persons covered by this Policy: 1. Duty to Disclose In connection with any actual or possible Conflict of Interest, all Interested Persons must disclose the existence of their Financial Interest, Influence Interest, and/or a Competitive Interest and all material facts to the Board and the Chair of the relevant committee. Disclosure as used in this Policy shall mean promptly providing to the Board and Chair of the relevant committee a written description of all relevant facts comprising the real or apparent Conflict of Interest. 2. Determining Whether a Conflict of Interest Exists Upon review of the volunteer s disclosure of the possible Conflict of Interest, and all material facts related thereto, the Board and the Chair of the relevant committee may conduct additional inquiry, including an interview with the volunteer or person compensated by NCBTMB, regarding the Conflict of Interest. Thereafter, the Board and the Chair of the relevant committee, shall determine the appropriate action to be taken in connection with the Conflict of Interest. 3. Conflict of Interests of Board Members A Board Member who is an Interested Person may make a presentation to the Board at a Board meeting. After such presentation, such Board member shall leave the Board meeting in order for the remainder of the Board to consider, discuss and vote on whether a Conflict of Interest exists and the appropriate action related thereto. The Chair of the Board, with the approval of the Board, may, if appropriate, appoint a disinterested person or committee to investigate alternatives to a proposed transaction or arrangement which is the subject of the Conflict of Interest. After exercising due diligence, the Board shall determine whether NCBTMB may obtain a more advantageous transaction or arrangement with reasonable efforts from a person or entity that would not give rise to a Conflict of Interest. If a transaction or arrangement is advantageous to NCBTMB, notwithstanding the Conflict of Interest, the disinterested members of the Board shall determine whether: (i) the transaction or arrangement is in NCBTMB s best interest and for its own benefit; (ii) the transaction is fair and reasonable to NCBTMB; and (iii) NCBTMB shall enter into the transaction or arrangement. 4. Conflict of Interests of Non-Board Members Volunteers who are not Board Members, or individuals who are compensated by NCBTMB, who are Interested Persons may make a presentation to the Board at a Board meeting. After such presentation the Board shall consider, discuss and vote on whether a Conflict of Interest exits and the appropriate action related thereto. The Chair of the Board, with the approval of the Board, may, if appropriate, appoint a disinterested person or committee to investigate alternatives to a proposed transaction or arrangement which is the subject of the Conflict of Interest. After exercising due diligence, the Board shall determine whether NCBTMB may obtain a more advantageous transaction or arrangement with reasonable efforts from a person or entity that would not give rise to a Conflict of Interest. If a transaction or arrangement is advantageous to NCBTMB, notwithstanding the Conflict of Interest, the 8

disinterested members of the Board shall determine whether: (i) the transaction or arrangement is in NCBTMB s best interest and for its own benefit; (ii) the transaction is fair and reasonable to NCBTMB; and (iii) NCBTMB shall enter into the transaction or arrangement. 5. Proscribed Activity by Persons having a Conflict of Interest Any individual that has a Conflict of Interest that is not waived by the Board shall abstain from taking any action in connection with matter, transaction or arrangement that is the subject of the Conflict of Interest, including without limitation, making motions, voting, executing agreements, or taking any other similar direct or indirect action on behalf of NCBTMB. 6. Violations of the Conflict of Interest Policy a. If the Board has reasonable cause to believe that an Interested Person has failed to disclose actual or possible Conflicts of Interest, the Board shall inform the person of the basis for such belief and afford him or her an opportunity to explain the alleged failure to disclose. b. If, after hearing the response of the person and making such further investigation as may be warranted under the circumstances, the Board determines that the person has inappropriately failed to disclose an actual or apparent Conflict of Interest, the Board shall take appropriate disciplinary and corrective action. D. Records of Proceedings The minutes of the Board shall contain: 1. The names of the persons who disclosed or otherwise were found to have a Financial Interest, Influence Interest, and/or Competitive Interest, the nature of the Financial Interest, Influence Interest and/or Competitive Interest, any action taken to determine whether a Conflict of Interest was present, and the Board s decision as to whether a Conflict of Interest in fact existed. 2. The names of the persons who were present for discussions and votes relating to the transaction or arrangement, the content of the discussion, including any alternatives to the proposed transaction or arrangement, and a record of any votes taken in connection therewith. E. Annual Statements Each person working with or for NCBTMB, whether compensated or volunteer shall annually sign a statement that affirms that such person: 1. has received a copy of the Policy; 2. has read and understands the Policy; and 3. has agreed to comply with the Policy. 9

II. Conflict of Interest Disclosure Statement I have carefully read NCBTMB s Conflict of Interest Policy & Procedure (the Policy ) and understand the requirements of this Policy as it applies to me. Name: NCBTMB Role: I have the following Financial Interests, Influence Interest and/or Competitive Interest, as defined by the Policy, requiring disclosure under the Policy. Please describe the following Financial Interests: 1) Ownership and investment interests held by you or your family members in non-publicly traded entities or organizations (If none, write none. ); 2) Outside compensation arrangements between you (or your family members) and entities or organizations (If none, write none. ); and 3) List the name of any entity or organization from which you or your family received any gifts, prizes, or favors in excess of $50.00. (If none, write none. ) Please describe the following Influence Interests: 1) Any relationships, positions, or circumstances not disclosed above in which you or your family are involved that you believe could contribute to a Conflict of Interest (as defined in the Policy). (If none, write none. ) 2) All organizations in which you or your family members are officers or hold positions on the Board of Directors. (If none, write none. ) 10

Please describe the following Competitive Interests: 1) All circumstances whereby you or your family members may or will gain a competitive and/or economic advantage resulting from NCBTMB s involvement or lack of involvement with another person or entity. (If none, write none. ) I hereby certify that the information set forth above is true and complete to the best of my knowledge. I agree that should any actual or apparent conflicts not disclosed arise, I will report them to the NCBTMB Executive Committee as soon as I become aware of them. Signature: Date: 11

NCBTMB Confidentiality and Nondisclosure Agreement I understand that participation on the NCBTMB Board of Directors will require my review of highly sensitive and confidential business information. I am aware of my responsibilities and legal obligations to the National Certification Board for Therapeutic Massage & Bodywork, Inc., ( NCBTMB ) regarding the Confidential Information that I will be given access to while I serve as an NCBTMB Board Director. The following is a summary of such responsibilities and legal obligations, which I acknowledge and agree to by my signature below: 1. Confidential Information shall include data relating to NCBTMB generally, as well as specific NCBTMB examination and testing information, NCBTMB business plans, NCBTMB committee activities, NCBTMB applicant and certificant information, and any other information related to NCBTMB business. Confidential Information does not include any information in the public domain or otherwise known by me prior to becoming an NCBTMB Board Director and not made available to me by NCBTMB. 2. I will use or copy Confidential Information solely to fulfill my responsibilities as an NCBTMB Board Director and will destroy or return any copies in my possession once my term has ended. 3. I agree to follow the procedures established by NCBTMB to protect Confidential Information. 4. I will not disclose Confidential Information in whole or in part, in any manner whatsoever, to any person not participating in the specific and applicable NCBTMB activities in which I am involved as a Board Director without the written consent of the Chair or CEO of NCBTMB. I further understand that any unauthorized disclosure of Confidential Information to any third party on my part may result in my dismissal from the Board as dictated by current policy. 5. If I leave or otherwise terminate my service as an NCBTMB Board Director, I agree that the confidentiality and nondisclosure provisions herein will survive termination of my service as an NCBTMB Board Director. 6. I agree that this Agreement shall be governed by the laws of the State of Illinois. Name: Date: Signature: Position: 12

NCBTMB Code of Conduct for Volunteers (As Revised May, 2006) I. Introduction Volunteers play a critical role in the operation of NCBTMB and in the conduct of its activities. Volunteers receive rewards such as personal and professional development, recognition, skill development and personal satisfaction. In return, volunteers are expected to conduct their efforts in a manner that supports the core value and mission of NCBTMB, its goals and objectives. The mission of NCBTMB is to foster high standards of ethical and professional practice in the delivery of services through a recognized credible credentialing program that assures the competency of practitioners of therapeutic massage and bodywork. II. III. Purpose The purpose of the Code of Conduct is to provide a benchmark for the personal and professional behavior of volunteers as they fulfill their leadership duties. The code is an agreement between NCBTMB and the volunteer that has been written to facilitate mutual trust and accountability. The Code of Conduct has been developed to assist volunteers in assessing their own behavior and to guide them in knowing and accepting NCBTMB s expectations of their behavior. Volunteer Leader Responsibilities A. Knowledge 1. Volunteer leaders are responsible for understanding NCBTMB s philosophy, mission and its importance in safeguarding the public trust. 2. Volunteer leaders are responsible for reading, understanding and complying with NCBTMB s policies and procedures. 3. Volunteers are responsible for learning about and understanding the nature of the volunteer position they have accepted and its responsibilities and duties. 4. Volunteers are responsible for making use of available information and knowledgeable people to accomplish this. B. Accountability and Behavior 1. Volunteers will sign and abide by the Policies & Procedures statement in all applications to NCBTMB. 2. Volunteers are accountable for their performance and their personal behavior. 3. Volunteers behave in a professional manner, adhering to the NCBTMB Code of Ethics and Standards of Practice. 4. Volunteers behave, personally as well as professionally, in a manner that will merit the respect of others for the NCBTMB, and the profession of massage therapy/ bodywork. 5. Volunteers shall treat all individuals with courtesy and respect. 13

6. Volunteers when speaking publicly shall show respect for NCBTMB policies and initiatives. C. Confidentiality Volunteers shall respect the confidentiality of written and verbal communications. This shall include, but not be limited to: 1. sharing information only when authorized to do so; and 2. commenting publicly only on matters of fact with which the volunteer has personal involvement. D. Conflict of Interest Avoidance 1. Volunteers shall avoid personal and professional conflicts of interest while performing their duties and responsibilities for NCBTMB. 2. If at some point a conflict of interest or a potential conflict of interest arises, the volunteer shall inform NCBTMB. E. Volunteer Leader Responsibilities: Members of the Board In addition to volunteer leader responsibilities (above), Directors: 1. Understand and accept their fiduciary responsibilities to NCBTMB, the Board of Directors itself, Certificants and the consumer public. This understanding is reflected in the volunteer s performing his or her duties in a manner that is trustworthy and reflective of good stewardship. 2. Avoid conflict of interest and sign and abide by Conflict of Interest Statement for Volunteer Leadership. 3. Shall attend all Board of Directors meetings and understand that failure to do so may result in removal from the Board. 4. Sign and abide by Time and Travel Commitment statement. 5. Sign and abide by Policies & Procedures statement. 6. Sign and abide by other confidentiality and disclosure statements according to committee liaison assignment. 7. Shall disclose conflicts of interest as they pertain to Board function. 8. Shall not speak or act for the Board without proper authorization. 9. Shall maintain the confidentiality of documents and information. 10. Shall prepare for Board business and be responsible for executing Board responsibilities in creating policy. 11. Shall publicly support Board decisions. 12. Shall recognize the equal role and responsibility of each member of the Board. 14

13. Shall act fairly and be impartial and unbiased in their role of protecting the public. F. General Application of the Code The Code of Conduct is not only a set of written standards. The Code of Conduct is a demonstration of NCBTMB s volunteers commitment to upholding stated and expected behaviors, values and attributes, and to promoting and maintaining the highest standards of personal and professional conduct. The scope and implementation of the Code is regularly reviewed by the Board of Directors for currency, and to assure the Code remains mutually beneficial to NCBTMB and its volunteers. G. Authority The NCBTMB Board of Directors has the authority to review and take action on any complaint of violation of the Code of Conduct for Volunteers. A written complaint, which may be brought by anyone, should be submitted to the Executive Committee. Members of the Executive Committee will record the date of receipt and address the complaint. IV. Statement of Commitment to the Code of Conduct NCBTMB requires a statement of commitment from its volunteers. As a volunteer for the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB), I have read and understood the above stated Code of Conduct. I understand that violation of the Code may result in my removal from my volunteer and/or leadership position. I agree that it is my individual responsibility to abide by the Code of Conduct, NCBTMB Code of Ethics and Standards of Practice. I commit myself to ethical conduct as a professional and in my volunteer role. Print name Signature Volunteer position Date 15

Policies & Procedures I,, agree to abide by the policies and procedures of the National Certification Board for the Therapeutic Massage & Bodywork. I understand that failure to do so will result in my being removed from the Board of Directors. I,, understand that remaining in good standing with NCBTMB is required, including maintaining national certification. Failure to do so may result in removal from the Board. Name: Signature: Date: 16

Time and Travel Commitment To be a member of the NCBTMB Board, you are required to attend all of the face-to-face meetings and phone conference calls. You may also be delegated to be a liaison to one of our standing committees or task forces. The following is a brief outline of the time and travel commitments for which you must be available: Up to four (4) two-and-one-half day meetings each year. Plus be able to travel to and from the meetings. Monthly conference calls, usually held for no more than two hours each. Attend a one-day orientation as a new board member. Represent NCBTMB (as requested and assigned) at two or three venue events. Represent NCBTMB (as requested and assigned) as an ambassador at local events or special interest events as they arise. Prepare in advance for board meetings and participate in board discussion, adding to the discussion as appropriate. Participate in other meetings as they arise, such as strategic planning and leadership development. I,, have read the above time and travel commitment statement and understand the time and travel commitment required. I agree to fulfill the obligations set forth and I understand that failure to do so may result in removal from the Board. Name: Signature: Date: 17

Attestment to No Criminal Activity In an effort to better serve the public trust, NCBTMB reserves the right to perform a criminal history background check and to deny an application or remove a credential based on the commission of a felony. Moreover, NCBTMB considers the prevention of sexual misconduct in massage and bodywork to be important in protecting the public. Consequently, NCBTMB may, in its discretion, deny an application or remove a credential based on the commission of a crime involving sexual misconduct. Answers to the following questions are mandatory. Failure to respond to each question will result in the application being returned. Failure to provide accurate, true and correct information shall constitute grounds for denial of your application, withdrawal of candidacy or removal from office if elected. Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? Please include all misdemeanors and felonies, even if the court withheld adjudication so that you would not have a record of conviction. For the purposes of this question, driving under the influence and driving while impaired are not considered minor traffic offenses. Yes No Have you ever been charged with a felony and pleaded guilty to, or been convicted of a lesser charge (e.g. misdemeanor)? Yes No Have you ever been charged with a felony that has yet to be dismissed? Yes No Are you now or have you ever been a defendant in a civil litigation in which the basis of the complaint against you was alleged negligence, malpractice, lack of professional competence, or sexual misconduct? Yes No Is there currently pending against you, in any state or jurisdiction, a complaint against your professional conduct or competence? Yes No With respect to any of the questions above to which you answered Yes, did any of the proceedings involve sexual misconduct? Yes No If you answered Yes to any of the above questions, you must submit the following before your application will be considered complete: 1. A complete written explanation of the circumstances surrounding the proceedings, including a narrative describing: a. Where the incident occurred b. The date the incident occurred c. The outcome of the proceedings d. Any penalty/sentence associated with the incident e. When the penalty/sentence was or will be fulfilled or completed 2. Copies of court documents. If the documents are not available, indicate the jurisdiction in which the proceedings occurred and why the documents are not available. 18

The more information that you provide, the less time will be needed to review your application. If all of the appropriate information is not provided, the processing of your application will be delayed and your application may be considered incomplete. All information submitted shall remain confidential, except that it may be disclosed to NCBTMB staff and legal counsel for processing and to law enforcement agencies, and state, county and/or local governmental agencies. The information I have provided is accurate, true and correct to the best of my knowledge. I agree to inform and release to the NCBTMB or its agents all pertinent information concerning criminal activity that occurs during my term on the NCBTMB Board of Directors, should I be elected. Additionally, I am aware of NCBTMB s policy regarding criminal convictions and NCBTMB s right to conduct an investigation of any violations of its policies. Name: Signature: Date: 19