Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date

Birthdate

YYYY

Title/Profession

Business/Work Information

Experience

Please list your current and past board experiences.

Expertise

Please list any skills or expertise.

Board Interest

Please detail your interests in joining this board, including any particular areas of interest.

Fundraising Experience

Please list any fundraising efforts you have participated in.

Availability

Are you able to commit to a minimum of 4-6 hours a month and quarterly board meeting>