LeadUS Mentoring Program 2015-16

Alexia Network Foundation Board of Directors Applicant Form
Personal Information
Name

Last NameFirst Name
Date

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Birth Date*

MonthDayYear
Demographic Information
Place of Birth
Gender Identity

MaleFemaleOther
Ethnicity
Nationality
Business/Work Information
Title/Profession
Company Organization
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Format: (000) 000-0000.
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 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 BBOT?
Please detail your interest in joining this Board
What type of Board tasks do you prefer?
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?
The Company 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 ResourcesDevelopmentProgramOther
How much time would you have to dedicate to the company (a week, a month, etc…)?
Board is an exciting and engaged working board. Board members are required to participate in aminimum of 4 board conference calls per year, 4 quarterly meetings, one annual face-to-face meeting oncea year, and a minimum of 11 standing monthly committee meetings, which occur outside of regular boardmeetings (this can happen by phone or internet). Board members are expected to be timely and present atevery meeting with a maximum of two absences from board meetings. Between work within and outside ofmeetings, hours of commitment would probably vary between 3-5 hours per month. Board members arealso encouraged to participate in fundraising and development activities, which include an annual gift toCompany that is personally significant and meaningful. Board members are expected to commit to the role fora minimum of one year. Will you be able to make this commitment to company?

YesNoMaybe
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.
Signature
Date

MonthDayYear
Date
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Alexia Network Foundation Board of Directors Applicant Form

Personal Information

Demographic Information

Business/Work Information