Applicant Name ______________________________________________________

Address _____________________________________________________________
This address is  __ Home      __ Work

Phone/Fax ____________________________

Email _________________________________

Referred by ___________________________

My greatest areas of interest in the work of the board of directors include:
__ Governance
__ Development of Policies and Procedures
__ Financial Management
__ Fundraising
__ Planning
__ Community Outreach (public relations)
__ Board Perpetuation
__ Other: ________________________________________________________________
    (nominating, training)

The reason I am interested in serving on the board of directors at this time is:

The reason this organization is of interest to me is:

My past involvement with the organization includes:

The unique skills/expertise/perspective I am able to bring to this board of directors include:

I anticipate that the personal benefits I will receive by being on the board include:

I feel that the benefits to me To be an effective board member, I may need training or mentoring in the following:

I am willing to commit the following to the organization for my tenure on the board of directors:

__ Monthly participation in board-related activities (meetings, committee work, outreach) Number of hours each month: ___

__ Attendance at an annual full-day planning/training retreat

__ An annual financial contribution to the organization

Other information I would like to be considered as part of my application to serve on the board of directors: