Public Company Directors and Officers Questionnaire Form
Please complete this form to provide information necessary for evaluating your candidacy or current role as a public company director or officer.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Current Company and Position/Title
*
Are you currently an independent director/officer as defined by the company’s policies?
*
Yes
No
Not sure
Please disclose any relationships, transactions, or interests that may present a conflict of interest with the company.
List all prior service as a director or officer for any public company in the past 10 years.
Do you currently own, or have you owned in the past year, any securities of this company?
*
Yes
No
Have you ever been subject to any legal, regulatory, or disciplinary proceedings related to your professional conduct?
*
Yes
No
Professional Reference (Name, Position, Contact Information)
Are you currently available and eligible to serve as a director or officer of a public company?
*
Yes
No
Submit
Should be Empty: