Board Member Application Name* First Last Date Date Format: MM slash DD slash YYYY Home Phone*Buisness PhoneCell PhoneHome Address* Street Address City State / Province / Region ZIP / Postal Code Business Address* Street Address City State / Province / Region ZIP / Postal Code Occupation*FaxEmail* Please indicate your preference - Mail correspondence to:* Home Business Receive Phone Calls at:* Home Business Cell Experience, Skills, and ExpectationsResumePlease also include any affiliations or organizational memberships, as well as the names and contact information for three personal and/or professional references. Special Skills/Areas of Expertise: (Please check all that apply)*AccountingCommunity ActivistCommunity PlanningEducation/AcademiaEntrepreneurshipEvent PlanningFinanceFor Profit BusinessFund DevelopmentGrant WritingHuman ResourcesLegalLegislation/Policy MakingMarketing/ Public RelationsMediaNonprofit ManagementNonprofit GovernanceResearchRisk ManagementStrategic PlanningTechnologyPlease outline any current or previous experience with Board service:Why are you interested in becoming an ACCORD Board Member?How do you feel you can best contribute your time and effort to help ACCORD achieve its mission?Other Comments:* I understand that I will be subject to a criminal records and a child abuse state central registry check, to be made concerning my suitability as a board member. I understand the information in this application and otherwise obtained will be used only for the purpose of determining my eligibility as a board member. All information will be held in confidence. Background check criteria used in the selection of board members will be such as to insure that the individual is able to meet the responsibilities of a volunteer of ACCORD. No individual will be rejected based on race, color, religious creed, national origin, gender, age, marital status, sexual orientation or any other characteristic protected by law.Full Name ( Used as Signature)*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NameThis field is for validation purposes and should be left unchanged.