Board of Directors Interest Form

Full name*

First NameLast Name

Email*

Confirmation Emailexample@example.com

Phone Number*

Please enter a valid phone number.

How should we address you?*

She/herHe/himThey/themOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Affiliation (company, faith community, neighborhood, or other affiliation)*

Habitat must meet certain requirements pertaining to legal status, organizational structure, capacity and board composition. All information reported will be kept confidential. Please answer to the best of your ability.

Please select all that apply.*

I am a low-income resident under the HOME Program definition (Household income is <80% Area Median Income)I am an elected representative of a low-income neighborhood organizationI am a public official, employee or appointee of a governmental entityN/A - None of the above statements apply to me.

Defining low-income resident

A low-income resident is one whose annual household income is under 80% of the Area Median Income.

1 person: $66,000

2 people: $75,500

3 people: $84,850

4 people: $94,250

5 people: $101,800

6 people: $109,350

Defining “public official, employee or appointee by a governmental entity”

• Public officials include any individual who is an elected or appointed member of any governmental entity (e.g. a city council member, a member of the local zoning board, a member of a local public housing authority board, etc.).

• A government employee is anyone who is employed by a governmental entity on a full or part time basis, even if that individual’s job function is not related to housing, HUD programs, or other federal funding or appointed to a position for which they are compensated.

• An appointee is anyone who has been appointed to the board of directors by a governmental entity even if that person is not otherwise a public official or governmental employee (e.g. a member appointed to the board by the local mayor).

Why are you interested in serving on Habitat's Board of Directors?*

What skills, experience or perspective would you bring to Habitat?*

Is there anything else you'd like us to know?*

Resume*