APPLICATION FOR BOARD MEMBERSHIP

Application for Board Membership

CSRA Economic Opportunity Authority, Inc.

1261 Greene St.

Augusta, Georgia 30903

706-722-0493
Name:
Date

MonthDayYear
Date
Home Phone:
Business Phone:
Cell Phone:
Home Address: Street & Number:
City, State, Zip
Email
example@example.com
County of Residence:
EOA District:
Gender:
Race:
Age Category:

18-33 Yrs.34-49 Yrs.49-64 Yrs.65 Yrs. & Above
Present Occupation/Position:
Employer:
Employer Address: Street & Number:
City, State, & Zip:
If retired, last position held:
Have you been nominated to represent an EOA low-income 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 Organization to which you belong:
*Information requested for monitoring purposes
Board 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?

Fiscal management or AccountingEarly Childhood Education and DevelopmentEducation (other than Early Childhood)Business AdministrationCommunity AffairsElder ServicesHealth ServicesHousingFundraisingInformation TechnologyOther
If yes to any, please describe background and/or expertise:
Are you a licensed attorney?
If 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?

YesNo
Do you, any family members, or any entities with which you are assoiciated, as an owner, partner, employee, officer, board member, or otherwise do busienss with the Community Action Agency? If yes, please describe below:
If selected, please indicate below the committee that best represents your area of expertise:

Financial & Operations CommitteePersonnel CommitteeEvaluation & Planning CommitteeBylaws CommitteePublicity Committee
On which committee(s) would you be most interested in serving?

FinancePersonnelBylawsPlanningPublicity
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:
Name:
Signature

Clear
Date

MonthDayYear
Date
Please attach current resume:

Cancelof
Should be Empty: