LeadUS Mentoring Program 2015-16

Board Member Applicant Form
Personal Information
Name

Last NameFirst Name
Date

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Birth Date

MonthDayYear
Date
Demographic Information
Place of Birth
Gender Identity

Other
Ethnicity
Nationality
Business/Work Information
Title/Profession
Please list your current and past Board experiences
Other Volunteer Experience:
Skills & Expertise
What do you hope to accomplish as a board member?
What experiences, expertise, connections, or resources would you bring to Pure Religion Co?
Please detail your interest in joining this Board
The Company Board will initially have 5 standing committees: (1) Research & Development, (2)Finance, (3) Communications, (4) Marketing & Public Relations and (5) Human Resources. Please check all that you would be interesting in joining.

Other
What type of Board tasks do you prefer?
Please let us know if you have any specific project ideas you would like to propose.
Time
Board is an exciting and engaged working board. Board members are required to participate in a minimum of 11 standing monthly committee meetings, which occur outside of regular board meetings (this can happen by phone or internet). Board members are expected to be timely and present at every meeting with a maximum of two absences from board meetings. We estimate that board service could be a commitment of 5 to 10 hours each month. Board members are also encouraged to participate in fundraising, special events and development activities. Will you be able to make this commitment to company?
Do you have any concerns or potential conflicts that may serve as impediments to this time commitment? If so, how will you manage the demands on your time?
Fundraising

Among other responsibilities, board members play a key role in raising funds for our organization. It is an expectation of board service that you will introduce people in your sphere of influence to our work and invite them to know and do more – as prospective volunteers, board members, staff and as donors. Our organization commits to providing you with the information and tools necessary for you to stand as a vocal and visible ambassador for our work. Further, we expect each board member to make a quarterly financial commitment of $75 for each year of service on the board.
Is there any other information you would like to provide that is relevant to your application?
What is your preferred method of contact/communication?
After your application has been reviewed you may be asked to interview in order for us to better get to know you. Please have a list of references available upon request.

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. An electronic signature is accepted.
Signature
Date

MonthDayYear
Date
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Board Member Applicant Form

Personal Information

Demographic Information

Business/Work Information

Skills & Expertise

Time

Fundraising