Application for Appointment to the Board
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email Address
Please check the education/skills you can contribute to our board
Accounting
Education
Investment
Planning
Fund raising
Knowledge of Service
Technology
Volunteer at Organization
Community Relations
Public Speaking
Management
Advocacy
Marketing
Other
(please explain other)
Are you a person with a disability, or a family member of a person with a disability?
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On what other boards have you served?
What is your interest in board service?
What is your interest in P.R.I.D.E., Inc.?
What is your understanding of P.R.I.D.E., Inc.?
Will you regularly attend board meetings?
Yes
No
Do you have time to give to P.R.I.D.E.,Inc.?
Yes
No
When are you available?
Signature (Type Full Name)
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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P.R.I.D.E., Inc
Conflict of Interest Statement
Name
First Name
Last Name
Place of Employment
Please check option A or B
A. I am not employed by, or on the Board of Directors of, or in a policy-making position for, or a consultant to, any agency or organization or person who is deriving or will likely derive any income from P.R.I.D.E., Inc.
B. I may have a potential or existing conflict of interest which is publicly stated on this form:
If option B is your answer please explain
Signature (Type Full Name)
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Should be Empty: