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