Application/Nomination for USSI Board of Directors

 

 

Name  (Please Print)_________________________________________________________________________

 

Address____________________________________________________________________________________

 

______________________________________________________________________________________________

 

Phone ________________________________________________________________________________________

 

Are you available to devote 10-12 hours per month to Board activities, including Board and committee meetings?   ____Yes  ____No

 

What talents do you feel you can contribute to the Board?

 

______________________________________________________________________________________________________

 

Why are you interested in serving on the USSI Board of Directors?

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

What other non-profit board have you served (please include dates)? 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

 

Are you currently serving on a non-profit Board?  ____yes  ___no

 

If yes, which one __________________________________________________________________________________

 

______________________________________________________________________________________________________

 

Can we contact them about your Board service?     _______ Yes       ______No

 

 

Please list three references

 

Name ______________________________________________________________________________________

 

Address_____________________________________________________________________________________

 

Phone ___________________________________________

 

 

 

Name _________________________________________________________________________________________

 

Address ________________________________________________________________________________________

 

Phone ________________________________________________

 

 

Name ____________________________________________________________________________________________

 

Address ___________________________________________________________________________________________

 

Phone ________________________________________________________________________________

 

Thank you for your interest in serving on the Upper Susitna Community/Senior Center Board of Directors

 

 

 

 

 

___________________________________________________________                      ___________________                      

Signature                                                                                           Date

 

 

 

 

 

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USSI Executive Committee Use Only

 

______ Nominee has had a personal meeting with a member of the Board

 

______ Nominee application reviewed by committee    Date __________

 

_____  Nominee has attended a Board meeting                Date _________

 

______ Nominee was interviewed by committee             Date ___________

 

Recommended for election/appointment to the Board Of Directors

 

________ Yes      ______No     Comments:

 

 

 

 

9/6/2017 - USSI