The Impact Center Governing Board Application
Thank you for your interest in the Governing Board, which provides legal and fiduciary oversight to The Impact Center. To apply to become a member, kindly fill out the form below.
Candidate Information
Full Name
*
Email
*
example@example.com
Residence Information
Address - Line 1
*
Address - Line 2
City / State / ZIP
*
Residence Phone (best contact)
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Information
Address - Line 1
*
Address - Line 2
City / State / ZIP
*
Employer Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
*
Please Select
Work
Residence
Type of Business or Organization
Primary Service(s) Done
Area / Population Served
Additional Information
Board and Committee Experience (Organization / Role / Dates)
List Education, Training, and/or Certifications
List Awards/Honors Received
How would The Impact Center benefit from your involvement on the Board of Directors?
*
Skills and Additional Information
Skills and Additional Information
*
What skills and knowledge are you willing to bring to our Board of Directors?
Rows
Very experienced
Some experience
Little or no experience
Board Development (Recruitment, Training, Evaluation)
Program Planning & Evaluation (Trainings, Outreach, Advocacy)
Marketing (Media, Communication, Website Development)
Fundraising
Finance/Accounting
Financial Management & Control
Grant Writing
Personnel, Human Resources, Policy Development
Historic Preservation
Law/Legal Resources
Administration/Management
Non-Profit Experience
Teaching/Instruction
Special Events
Any skills you have that are not listed?
Groups / Organizations / Businesses you could serve as a liaison for
Anything else you'd like to share?
Certification
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Boards and Committees - Organization / Role / Dates (List)
Submit
Submit
Should be Empty: