LeadUS Mentoring Program 2015-16

Board of Directors Applicant Form
Personal Information
Name

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Birth Date*

MonthDayYear
Demographic Information
Place of Birth
Gender

MaleFemale
Ethnicity

Black or African AmericanWhite or CaucasianLatino or HispanicAmerican Indian or Alaska NativeAsian
Business/Work Information
Title/Profession
Company Organization
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Ext
Please list your current and past Board experiences
What are your current associations and/or club affiliations (include titles if possible)
Please list your skills and expertise
What is your educational background?
Please describe in details some of your greatest 3 strengths and 2 weaknesses
What do you feel is essential to ensure that the Board and staff are successful in attaining the goals for this organization?
What experiences, expertise, connections, or resources would you bring to POC?
Please detail your interest in joining this Board
What type of Board tasks do you prefer?
Directors of the POC Board might take on special projects, in addition to their Board responsibilities, in order to better assist POC, have you ever worked with youth (teenagers) before? If so, what was your experience?
Have you ever been engaged in any specific fundraising efforts? If so with whom, how, and what was the amount raised? Are you comfortable playing an active role in assisting POC with fundraising efforts?
The POC Board will initially have 4 standing committees: (1) Board Building & Governance, (2)Development, (3) Finance & Human Resources, and (4) Program. Please check all that you would be interesting in joining.*

Board Building & GovernanceFinance & Human ResourcesDevelopmentProgram
How much time would you have to dedicate to POC (a week, a month, etc…)?
Do you understand that specifically, even when acting in good faith, board members are subject to personal liability, which may affect their personal financial status because of their business decisions.*

YesNo
POC's Board is an exciting and engaged working board. Board members are required to participate in a minimum of 4 board conference calls per year, 4 quarterly meetings, and one annual face-to-face meeting once
a year. As we GROW and increase the organization, these meetings will be more frequent (on an AS-NEEDED) basis.

Board members are expected to be timely and present at every meeting with a maximum of two absences from board meetings. Between work within and outside of meetings, hours of commitment would probably vary between 3-5 hours per month.

Board members are also encouraged to participate in fundraising and development activities, which include an annual gift to POC that is personally significant and meaningful.
PLEASE ADD ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO CONSIDER
Board members are expected to commit to the role for a minimum of one year. Will you be able to make this commitment to POC?

YesNoMaybe
Please indicate any concerns below:
After your application has been reviewed you may be asked to interview in order for us to better get to know you. Please have a list of references available upon request.

Thank you for your interest.

I certify, by my signature, that the information contained within this application and all supporting
documents (i.e., resume, recommendation letters, etc.) is true, accurate, and complete to the best of my
knowledge. An electronic signature is accepted.

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Power of Choice Ministries Mentorship program, does not discriminate on any basis including race, sex, age, religion, ect
Should be Empty:

Board of Directors Applicant Form

Personal Information

Demographic Information

Business/Work Information