SELF RELIANCE CENTER FOR INDEPENDENT LIVING BOARD MEMBER APPLICATION
First Name (required)
Middle Name
Last Name (required)
Marital Status (optional)
Spouse's Name (if applicable)
Residence Address Line 1 (required)
Residence Address Line 2
City (required)
State (required)
Zip (required)
Cell Phone
Home Phone
Work Phone
Email Address (required)
Indicate your preference for receiving information PhoneEMail
Regular Mail Address
Business/Employer Name
Business Address Line 1
Business Address Line 2
City
State
Zip
Type of business
Title
Have you served on a Board(s) of Directors for other non profits? YesNo
Please provide date(s) and non profit organization names (if applicable)
Memberships in other non-profit organizations (List organization(s) name and address)
Organization 1
Organization 2
Organization 3
Brief Autobiography
Attach resume (10MB file size limit. Acceptable file formats are .PDF and .DOC)
Why would you like to join Self Reliance’s Board of Directors?
Please check the areas in which you possess experience or training Public/Private PartnershipsBoardsHuman ResourcesPrograms/ServicesLegalFinancialFundraisingMarketing/Public RelationsNon-ProfitsNetworkingTechnology/Social Media
Describe any additional skills, talents, relationships, expertise, or experiences you have that will benefit Self Reliance’s Board of Directors and the mission of the organization?
How did you initially become aware of Self Reliance?
Are you now or have you ever been related to or known an employee, Board member, funder, or consumer of Self Reliance? YesNo
If so please identify the person(s) and describe the relationship
Have you ever been employed by another Center for Independent Living? YesNo
If yes, what CIL?
Give the dates of employment and position title
Are there any conflicts of interest that might occur by your serving on the Self Reliance Board of Directors? YesNo
If yes, please explain