LeadUS Mentoring Program 2015-16

Board of Directors Interest

MidState Arc
Personal Information

Areas marked with an asterisk (*) are required.
Name

Last NameFirst Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Format: (000) 000-0000.
Email
example@example.com

Board of Directors Interest
I understand that this form is for interest to join our Board of Directors and not an open job position. By filling out this form, I agree to be contacted by the Executive Management team for the Board of Directors. For all job applications and inquiries, please visit www.midstatearc.org/career

Business/Work Information
Title/Profession (active or retired)
Company Organization (active or retired)
Work Phone (if applicable)
Format: (000) 000-0000.
Please list your current and past Board, Volunteer, and Civic experiences
Please tell us about your educational background

Please tell us a little bit more about yourself. Why would you like to join our Board?
Please tell us about your interactions and experience with individuals with I/DD and/or services for these individuals?
Please list any training or certifcations you have completed: