Board Application

APPLICATION FOR BOARD MEMBERSHIP CSRA ECONOMIC OPPORTUNITY AUTHORITY, INC. 1261 GREENE STREET POST OFFICE BOX 10104 AUGUSTA, GEORGIA 30903-2704
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home
Business
Cell
Home Address: Street and Number
Street and Number
City State and Zip
Email Address
example@example.com
County of Residence
EOA District
Sex
Race
Employer
Age Category
Employer's Address: Street and Number
Type a question
City State and Zip
If retired last position held
Have you been nominated to represent an EOA lowincome district
If yes which EOA District
Are you an elected public official?
Are you an appointed official?
If you are a public official state your position
Major organizations to which you belong:
Information requested for monitoring purposes
Boards and Commissions on which you have served in the past five years and positions held
Volunteer Activities:
Do you have a background of expertise in any of the following areas:

Other
Are you a licensed attorney?
yes please give license number
Please describe areas of the law in which you practice or with which you are familiar, including issues that come before the Board.
Are you a current or former Head Start Parent
Why are you interested in serving on the Board?
Are you willing to donate the necessary time to serve on the CSRA EOA, Inc. Governing Board and committees if selected?
Do you any family members or any entities with which you are associated as an owner partner employee officer board member or otherwise do business with the Community Action Agency If yes please describe below
If selected, please indicate below the committee that best represents your area of expertise:
On which committee(s) would you be most interested in serving?
Have you ever served as a member of the CSRA EOA Board of Directors
If "yes" give dates of Board membership: Are you related to any employee of CSRA EOA, Inc.? If "yes" give name and relationship:
Are you related to any employee of CSRA EOA INC.?
If yes, give name and relationship?
Name please print
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Based on the information in this application, the applicant would be classified as: Low-Income Representative Elected Official Representative
Please attach current resume?

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