YES

Board Of Directors Candidate Application

Last

First

Date

Street Address

City

Phone

Email

example@example.com

Employer Name

Employee Title

Employer Address

Employer Email

example@example.com

Board Position Applied for

Have you ever worked for the company or served as a Board Member for this company before?

YesNo

Have you served as a Board Member for another Non-Profit before?

YesNo

If yes, when

Have you ever been convicted of a felony?

YesNo

If yes, explain

Please list Boards & Committees that you serve on or have served on. List Organization, role/title, and years of service

Education/Training/Certificates

Why are you interested in serving on the Board of Directors for 2 Rivers Industries, Inc?

Explain how 2 Rivers Industries, Inc. would benefit from your involvement on the Board?

Is there anything else you think would be of interest or would like to share?

Skills, Experience & Interests

Are you able to attend at least FOUR meetings per year?

YesNo

Are you able to make a Three-year commitment to the Northeast Missouri Sheltered Workshop?

YesNo

Please attach a copy of your autobiography and resume'

I certify that my answers are true and complete to the best of my knowledge. Once you are approved as an active Board Member, you will be required to attend quarterly Board meetings, volunteer for any events held by 2 Rivers Industries, Inc unless the event interferes with preexisting obligations of the Board Member. If you miss ONE quarterly board meeting, the board will dismiss you as a Board Member unless you notify the Board President 24 hours prior to meeting. If this application is accepted, based on the information given, you understand that false or misleading information in this application or interview may result in my release.

Signature

Date