LeadUS Mentoring Program 2015-16

WVCBAPP Board of Directors Applicant Form

Use this form to apply to be a WVCBAPP Board member.
Before You Begin the Application

Ensure that all required documents are completed and available in one of the following formats: PDF, DOC, DOCX, XLS, XLSX, CSV, TXT, RTF, HTML, ZIP, MP3, WMA, MPG, FLV, AVI, JPG, JPEG, PNG, GIF.
Personal Information
Name*

Last NameFirst Name
Date*

MonthDayYear
Date
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Birth Date*

MonthDayYear
Business/Work Information
Title/Profession*
Company Organization*
Email*
example@example.com
Mailing 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 WVCBAPP? *
Please detail your interest in joining this Board.*
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/grant efforts? If so with whom, how, and what was the amount raised?*
WVCBAPP has the follow committees. Which would you be most interested in being a member of?*

CertificationRecertificationEthicsFinanceIC&RC liaisonWVAAPP liaisonGrant FundingCertification DevelopmentQuality ControlMedia and MarketingTechnologyOther
Which certification do you hold in good standing with the WVCBAPP?*

AADCADCCCJPCSPSI OR PSIIPRSS-MH OR PRSS-SUDNoneWVCBAPP Approved Provider
Have you ever had an license or credential revoked, suspended, or voluntarily fortified in any jurisdiction?*

Yes, I have outlined the circumstances belowNo
Explanation of my license or credential revocation, suspension, or voluntarily forfeiture.
How much time would you have to dedicate to the company (a week, a month, etc…)?*
WVCBAPP is an exciting and engaged volunteer working board. Board members are required to participate in minimum of 2 board meetings per year of the 4 quarterly meetings one annual face-to-face.

All meetings are face to face and held at the Dunbar, WV location. Board members are expected to be timely and present at every meeting with a maximum of two absences from board meetings.

Between work within and outside of meetings, hours of commitment would vary between 5-10 hours per month. Board members are also encouraged to participate in fundraising and development activities, which include an grant writing and credential development. Board members are expected to commit to the role for a minimum of two years.
Will you be able to make this commitment to WVCBAPP?*

YesNoMaybe
File Upload: Current Resume *

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File Upload: 3 letters of recommendation *

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After your application has been reviewed you may be asked to interview in order for us to better get to know you.

Thank you for your interest.

I certify, by my signature, that the information contained within this application and all supporting documents (i.e., resume, recommendation letters, etc.) is true, accurate, and complete to the best of my knowledge.
Signature*

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Date*

MonthDayYear
Date
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WVCBAPP Board of Directors Applicant Form

Personal Information

Business/Work Information