Online Board Member Application Name* First Last Email* Date* MM DD YYYY Phone*Preferred method of contact*EmailCallTextAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer*Job Title*Type of business/organization.*Primary service(s) and area/population served.*Please list boards and committees that you serve on, or have served on (business, civic, community, fraternal, political, professional, recreational, religious, social).*Include organization name, your role/title, and dates of service.Volunteer ExperienceInclude organization name, type of activities, and dates of service. , Education/Training/CertificatesHow do you feel HART would benefit from your involvement on the Board?*What do you hope to gain for yourself out of your participation on the Board?*HART’s board is a “working board” which means that board members commit to a significant amount of time volunteering in many different capacities throughout the organization. Will you have any regular schedule conflicts or time commitments that will inhibit you from attending board meetings or volunteering?*Skills, experience and interests.* Select All Administration/Management Community Service Education/Instruction Finance/Accounting Fundraising Grant Writing Nonprofit Experience Other Outreach/Advocacy Personnel/Human Resources Policy Development Program Evaluation Public Relations/Communications Special Events Check all that apply.Please list any groups, organizations or businesses that you could serve as a liaison to on behalf of HART.Awards, honors or anything else you’d like to share.If you are not selected as a member of the Board, or if you decide not to join, would you like to be a volunteer to assist our organization in various ways that match your skills and interests?*YesNoMaybe
