Board of Directors Application

First Name *

Last Name *

Email *

Phone 1 *

Phone 2

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Briefly describe why you would like to join our Board of Directors:

(500 characters only)

Your current organizational affiliations (names of the organization and your role(s):

Up to four

Which of your skills would you like to utilize on the Board? Check those that apply:

What would you like to get for yourself out of your participation on the Board, e.g., what types of experiences, skills to develop, interests to cultivate for you, etc.? (500 characters)

If you join the Board, you agree that you can provide at least 2-4 hours a month in attendance to Board and Committee meetings, and that you do not have any conflict-of-interest in participating on the Board. Please type your signature:

Today's date:

If you are not selected as a member of the Board, or if you decide not to join, would you like to be a volunteer to assist our organization in various ways that match your skills and interests?

Yes

No

Perhaps

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