SELF RELIANCE CENTER FOR INDEPENDENT LIVING BOARD MEMBER APPLICATION
First Name (required)
Last Name (required)
Marital Status (optional)
Spouse's Name (if applicable)
Residence Address Line 1 (required)
Residence Address Line 2
Email Address (required)
Indicate your preference for receiving information
Regular Mail Address
Business Address Line 1
Business Address Line 2
Type of business
Have you served on a Board(s) of Directors for other non profits?
Please provide date(s) and non profit organization names (if applicable)
Memberships in other non-profit organizations (List organization(s) name and address)
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?
If so please identify the person(s) and describe the relationship
Have you ever been employed by another Center for Independent Living?
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?
If yes, please explain