Sandra Blank
President

Samuel Sasser

LaVern Scharmer

Donna Leuhmann

David Bittner

Joan Thesing

Gerald Portman

Board Member Application

  • Date Format: MM slash DD slash YYYY
  • PLEASE READ PRIOR TO SIGNING


  • I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, would affect this application unfavorably. I agree that the DAC shall not be held liable in any respect if a Board of Director Membership offer is not extended, is withdrawn or my membership is terminated because of false statements, omissions or answers made by me on this application. Minnesota Statues, chapter 245A, and Minnesota Rule 11 require the Department of Human Services (DHS) to perform a background studies of individuals working in positions allowing direct contact with persons receiving services from programs licensed by DHS. The requested information will be used to perform a background study that will include, but will not be limited to, a review of criminal conviction records held by the Bureau of Criminal Apprehension and cases of substantiated abuse and neglect of vulnerable adults and maltreatment of minors. The statute and rule require that I must provide sufficient information prior to my first board meeting to ensure an accurate study. Refusal to provide the necessary information will result in disqualification and thus I cannot be a member of the DAC Board of Directors. The information received as part of the background study is classified as private information and cannot be released to anyone without my written consent. If I am found to have a disqualifying characteristic, the DAC will only be told that I am disqualified and will not be told what the information was that caused my disqualification. My Board of Director Membership with the DAC cannot be finalized until the results of the background check are returned. I have the right to appeal if a disqualification notice is received.

    I understand that being a board member at the DAC is "at will", which means that either I or the DAC can terminate the member relationship at any time, with or without prior notice, and for any reason not prohibited by statute.

    All board membership is continued on that basis. I understand that no supervisor or manager other than the Executive Director has any authority to alter the foregoing.

    I hereby acknowledge that I have read and understand the above statements.
  • Type your name to signify your signature
  • Date Format: MM slash DD slash YYYY