LeadUS Mentoring Program 2015-16

Board of Directors Application Form

Thank you for your interest in serving on the Green Cosmos Board of Directors. Kindly complete the following form to help us better understand your background and how your expertise aligns with our mission.
Personal Information
Name

Last NameFirst Name
Birth Date

MonthDayYear
Personal Email
example@example.com
Phone Number
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Demographic Information
Gender
Place of Birth
Ethnicity
Nationality
Business/Work Information
Title/Profession
Company Organization
Work Email
example@example.com
Work Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Motivation & Alignment
Why are you interested in serving on the Board of Directors for Green Cosmos? (Max 200 words)
What excites you most about the mission and work of Green Cosmos?
In your view, what are the key environmental challenges facing Zambia today?
Experience & Skills
Please outline your previous experience in leadership, governance, or board roles (if any).
What specific skills, expertise, or networks do you bring that will benefit Green Cosmos? (e.g. Legal, Finance, Fundraising, Strategic Planning, Environmental Policy, Youth Engagement)
Have you previously worked with NGOs, youth-led initiatives, or climate change programs? Please explain.
Please upload your CV

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Please upload your portrait picture

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Availability & Committment
Are you able to commit to quarterly board meetings and strategic sessions (in person or virtually)?
Can you volunteer an average of 5-10 hours per month for board-related duties and support?
Do you foresee any potential conflicts of interest that may affect your board service? If yes, kindly elaborate.
Potential conflicts of interest (If answered Yes above)
Character & Values
Describe your leadership style in 1–2 sentences.
How do you handle disagreement or conflict in a team or governance setting?
What values are most important to you as a board member?
References

Please provide two professional references we may contact:
Reference 1

First NameLast Name
Reference Email 1
example@example.com
Reference Phone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2

First NameLast Name
Reference Email 2
example@example.com
Reference Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Declaration
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
Should be Empty:

Board of Directors Application Form

Personal Information

Demographic Information

Business/Work Information

Motivation & Alignment

Experience & Skills

Availability & Committment

Character & Values

References

Declaration