PROSPECTIVE BOARD MEMBER PROFILE

PROSPECTIVE BOARD MEMBER PROFILE
Date

MonthDayYear
Date
Part of the nomination process involves introducing you to our Board. Please supply us with the information below. Board Meetings are held on the 2nd Monday of the month at 11:45 AM.
Could you attend?

YesNo
Name

First NameLast Name
Date of Birth:

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Cell)
Please enter a valid phone number.
Email
example@example.com
CAREER INFORMATION

(If you are retired, indicate that and list the job you held when working.)
Current Job Title
Employer
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Please enter a valid phone number.
How long have you been in that position or career?
Educational Background:
PERSONAL INTERESTS
COMMUNITY INVOLVEMENT
How long have you lived in area?
City/State of Birth
In what professional/civic/social organizations are you active?
References (names, addresses, phone numbers)
Why have you chosen to become involved with LifeSpan Resources?
Should be Empty:

Part of the nomination process involves introducing you to our Board. Please supply us with the information below. Board Meetings are held on the 2nd Monday of the month at 11:45 AM.