NOMINATION FORM

                           FOR THE BOARD OF DIRECTORS

                                 OF THE HORNEPAYNE COMMUNITY HOSPITAL

I,                                       , member in good standing and                             , also a member in good standing hereby nominate                           as a candidate for the Board of Directors.

I,                                       , member in good standing, hereby accept this nomination, and if elected, I promise to fulfill the duties and responsibilities of director of Hornepayne Community Hospital as outlined in the Public Hospital Act and the bylaws of the Hospital, to the best of my ability.

Signed:                                     

Date:                                       

 Updated Wednesday October 29, 2008