LICI Board of Directors Application Form

LICI BOARD OF DIRECTORS CANDIDATE REGISTRATION FORM

Thank you for expressing your interest in joining LICI (for-profit) Board! Use this form to provide useful information about yourself, to ensure the best match between you and LICI Board of Directors.
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Briefly describe why you would like to join our Board ofDirectors:*
Your current organizational affiliations (names of the organization and your role(s): *
What would you like to get for yourself out of your participation on the Board, e.g., what types of experiences, skills to develop, interests to cultivate for you, etc.? *
If you join the Board, you agree that you can provide at least 2-4hours a month in attendance to Board and Committee meetings, and that you do not have any conflict-of-interest in participating on the Board.*
Signature*

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LICI BOARD OF DIRECTORS CANDIDATE REGISTRATION FORM