Board Member Application Form

Name:
Address:
City:	State:	Zip:
Home Phone:		Email:
Employment
Job Description/Title:		Employer:
Employer Phone:		Employer Fax:
Employer Email:
Type of agency you would be interested in serving as a board member:

[ ] Health	[ ] Recreation	[ ] Elderly Services	[ ] Civic	[ ] Education
[ ] Faith Based	[ ] Substance Abuse	[ ] Women's Issues	[ ] Mental Health	[ ] Cultural
[ ] Youth	[ ] Environment	[ ] Volunteerism	[ ] Other
Your Talents:
Your Interests:
Please check all that are appropriate: Your background:
[ ] Corporate	[ ] Education	[ ] Homemaker	[ ] Student	[ ] Retiree
[ ] Management	[ ] Trades	[ ] Union	[ ] Media	[ ] Accounting
Your skills:
[ ] Marketing	[ ] Sales	[ ] Planning	[ ] Financial	[ ] Public Speaking
List of organizations to which you currently belong:
Attach your current resume and current biography with this completed form. This information enables us to make the most effective match for you.