Board of Directors Membership Application Form

Tripartite Board Membership Application

Thank you for your interest in volunteering. Eligible applicants are residents of Park, Hot Springs, or Teton Counties age 18+. Please complete all questions below.
Full Name*

First NameLast Name
Physical Address*

Street Address

Mailing Address

CityState / Province

Postal / Zip CodeCountry
Preferred E-mail*
example@example.com
Preferred phone number*
Format: (000) 000-0000.
Park CountyHot Springs CountyTeton County
YesNo
YesNo
YesNo
If yes: explain
YesNoI, don't know
if yes or not sure: explain
Yes,NoI, don't know
I acknowledge, Board members with a disclosed conflict must recuse themselves from discussion and voting on matters directly affecting that organization, including approval or amendment of MOUs or contracts.
Low-Income RepresentativeCommunity / Private Sector RepresentativePublic Official / Public Official Designee (if applicable)
Low-Income Seat Only
YesNo
Park County, WyomingHot Springs County, WyomingTeton County, Wyoming
I have personal lived experienceI currently serve low-income households through volunteer or community workI have past experience working with low-income householdsOther (short answer)
Community-based selection requirement

For this seat, YCAN must document a community-based selection/endorsement to represent the low-income sector.
A letter from an independent community group or council endorsing my selection (not a YCAN board member, employee, or contractor).I can participate in a community selection meeting if heldI’m not sure yet — please contact me about optionsOther
Community / Private Sector Seat Only
Business / workforceFinance / accountingEducationHealthcareHousing / homelessnessFaith-based community supportLaw enforcement / courtsNonprofit / community servicesOther (short answer)
Why do you want to serve on the YCAN CSBG Tripartite Board? (short paragraph)
What community needs do you see most often in your county? (short paragraph)
Required Acknowledgements
YesNo
YesNo
YesNo
I certify that I am not currently debarred, suspended, or otherwise excluded from participating in federal or state programs or public transactions. I further certify that I have not been convicted of, and am not currently under a civil judgment for, fraud or a criminal offense related to a public transaction or contract.No
If you answered “No,” please explain:
I certify that I have reviewed the YCAN Board Bylaws and Board Policies, including the Conflict of Interest and Confidentiality requirements, as posted on the YCAN website, and I agree to comply with them if appointed.
I understand that I will be required to complete and sign a Conflict of Interest disclosure and update it as required by YCAN policy.
I understand that service on the YCAN Board of Directors is voluntary and unpaid.
Date of Signature*

MonthDayYear
Date
Applicant Certification and Signature:I certify that the information provided in this application is true, complete, and correct to the best of my knowledge and belief. I understand that providing false or misleading information, or omitting material facts, may result in disqualification or removal if appointed.*

Clear
Should be Empty:

Tripartite Board Membership Application

Low-Income Seat Only

Community-based selection requirement

Community / Private Sector Seat Only

Required Acknowledgements