PROSPECTIVE BOARD MEMBER PROFILE

PROSPECTIVE ADVISORY COUNCIL MEMBER PROFILE
Date

MonthDayYear
Date
Part of the nomination process involves introducing you to our Advisory Council. Please supply us with the information below. Meetings are held every other month on the 3rd Monday (beginning in February) 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:

PROSPECTIVE ADVISORY COUNCIL MEMBER PROFILE