Board Member Application

Board Member Application
Full Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Business Name and Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Daytime Phone *

Area Code Phone Number
Evening Phone

Area Code Phone Number
E-mail *
Best Way to Contact You *

Phone Email
Honors and Awards
Organizational Affiliations (boards and committees on which you currently serve, or have served).
What skills, expertise, connections, etc., do you bring to the board to help accomplish our mission?
Please check areas of interest (check all that apply)

Finance, Accounting Personnel, Human Resources Administration, Management Nonprofit Experience Governance Community Service Policy Development Program Evaluation Public Relations, Communications Healthcare/Hospitals Education Special Events Grant Writing Fundraising Individual Donor Meetings Outreach, Advocacy Legal Other
Please list other areas of interests:
How will you cultivate support and involvement? Please keep in mind your interests, talents, networks, and the activities you enjoy.
What do you hope to gain from being a member of the board?
Please list any groups, organizations or businesses where you can serve as a liaison on behalf of KSS.
Is there anything else you would like to share?
How did you hear about this opportunity?
Thank you for your interest in serving on the

Keystone Science School Board of Directors!
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