LeadUS Mentoring Program 2015-16

Board of Directors Applicant Form
Fellowship House, Inc.
Name

Last NameFirst Name
Preferred 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
Gender Identity

MaleFemaleOther
Ethnicity
Nationality
Business/Work Information
Title/Profession
Company Organization
Work Phone
Please scroll down through the mission statement and conflict of interest attachment below:
As a Member of the Fellowship House Board of Directors, I,First Name* Last Name* have read and agree to comply with the established Board Responsibilities and Guidelines.
If you currently know any Fellowship House Board Members, please list them below:
Please list your current and past Board experiences
What are your current associations and/or club affiliations? (include titles if possible)
What experiences, expertise, connections, or resources would you bring to Fellowship House?
After your application has been reviewed, you will be invited to attend the next board meeting to introduce yourself and meet the rest of the board of directors. You will be excused from the meeting to have your membership voted upon by sitting board and

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

Fellowship House, Inc.

Demographic Information

Business/Work Information