Board of Director Application

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First Name *

Last Name *

Cell Phone *

Address *

Email *

Please describe your educational background, including any special courses or studies that may contribute to your effectiveness on this Board. *

Please provide your occupational background, including current employer, if applicable. *

Please describe your past and present community service. *

Do you currently, or have you ever, served on any other Boards or Commissions (business, civic, community, fraternal, political, professional, recreational, religious, or social)? If so, please indicate the organization, your role, and dates of service. *

Are you aware of any involvement by you within the past year, or prospective involvement in the next year, that could reasonably be interpreted as a possible conflict of interest or could reasonably be viewed as having an appearance of a divided interest or loyalty on your part? If so, please describe.

Do you have any private business activity or personal services with this organization? If so, please explain.

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