LeadUS Mentoring Program 2015-16

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
Home Phone
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
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 Elder Love USA, Inc?
Please detail your interest in joining Elder Love USA Inc's Board of Directors
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?
Elder Love USA has several committee opportunities: (1) Board Building & Governance, (2)Development & Expansion, (3) Fundraising, and (4) Programs. Please check all that you would be interesting in joining.

Board Building & GovernanceFundraisingDevelopment & ExpansionProgramsOther
How much time would you have to dedicate to Board activities (a week, a month, etc…)?
Elder Love USA is forming an exciting and engaged working board. All Board members are covered by our D & O insurance. Board members are required to participate in 4 face-to-face quarterly meetings at the corporate office in Palm Desert. Board members are expected attend 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 includes a give or get policy. Board members are expected to commit to the role for a minimum of one year with an opportunity to continue to serve. Will you be able to make this commitment to Elder Love USA, Inc?

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 is true, accurate, and complete to the best of my knowledge. An electronic signature is accepted.
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Board of Directors Applicant Form

Personal Information

Demographic Information

Business/Work Information