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Board Member Application
Board Member Applicant Information
Name
(Required)
First
Last
Title/Organization
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Current Position or Employer
Start Date
End Date
Company Name
Company Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Company Phone
Responsibilities
Supervisor Name
Supervisor Title
May we contact this employer for a reference?
Yes
No
Non-Profit Experience
Organization Name
Position(s) Held
Responsibilities
May we contact this organization for a reference?
Yes
No
Organization Name
Position(s) Held
Responsibilities
May we contact this organization for a reference?
Yes
No
Additional Questions
Summarize Your Special Skills or Qualifications
Please check all that apply.
Fundraising Technology / IT Development
Special Events Marketing / PR
Finance
Strategic Planning Management / HR
Community Affiliation
Evaluation Legal
Other
Have you ever pleaded guilty, no contest or been convicted of a crime?
(Required)
Answering yes to the question does not constitute an automatic rejection for the board seat.
Yes
No
Please provide dates and details.
Emergency Contact Information
Name
(Required)
First
Last
Relation
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Final Steps
Consent
(Required)
By checking this box, I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal from the Board of Directors. I have read the Board Engagement Expectations document and am willing to participate and/or have authorization from my employer to participate as outlined.
By checking this box, I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal from the Board of Directors. I have read the Board Engagement Expectations document and am willing to participate and/or have authorization from my employer to participate as outlined.
Full Name
(Required)
Typing your name in this field acts as your signature.
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