LeadUS Mentoring Program 2015-16

Board of Directors Application
Personal Information
Name*

Last NameFirst NameSuffix
Today's Date*

MonthDayYear
Date
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobil Phone Number
Home Phone Number (Optional)
Date of Birth*

MonthDayYear
Date of Birth*

MonthDayYear
Date
Demographic Information
Male or Female
Ethnicity
Nationality (Optional)
Business/Work Information
Title/Profession
Company Organization
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number (Optional)
Extension
Please list your current and past Board experiences. If none, put N/A
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 strengths and 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 Complete The Puzzle
Please detail your interest in joining this Board
What type of Board tasks do you prefer?
Directors of Complete The Puzzle might take on special projects, in addition to their Board responsibilities. Please let us know if you have any specific project ideas you would like to propose.
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 with fundraising efforts?
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Board of Directors Application

Personal Information

Demographic Information

Business/Work Information