APPLICATION FOR BOARD MEMBERSHIP

Application for Board Membership

CSRA Economic Opportunity Authority, Inc.

1261 Greene St.

Augusta, Georgia 30903

706-722-0493

Name:

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:

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?

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?

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:

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:

Name:

Signature

Date

Please attach current resume: