Board of Directors Candidate Application
Title
First Name
Middle Name
Last Name
Preferred Name
Gender	ManNon-binaryPrefer not to sayWoman
Residence
Address 1
Address 2
City
State/Province	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoU.S. Minor Outlying IslandsVirgin IslandsArmed Forces AmericasArmed Forces Europe, the Middle East, anArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavut TerritoryOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory
Zip
Email
Phone
Employer
I am	Employed Un-Employed Retired
Company Name
Type of business or organization
Primary service(s) and area/population served
Business Phone
Business Email
Business Address
Communication Preference	Personal Phone Personal Email Business Phone Business Email
Please list boards and committees that you serve on, or have served on (business, civic, community, fraternal, political, professional, recreational, religious, social). Please include organization name, role/title, and dates of service.
Education/Training/Certificates
Optional – Have you received any awards or honors that you’d like to mention?
Do you have any interests/experiences that you can share that directly relate to domestic violence/sexual assault?
How do you feel The Shelter would benefit from your involvement on the Board?
Skills, expertise, and interests. Please select all that apply. Finance, accounting Personnel, human resources Administration, management Nonprofit experience Community service Policy development Program evaluation Public relations, communications Education, instruction Special events Grant writing Fundraising Outreach, advocacy
Please list any additional skills, expertise, and interests not listed above that you would like to add.
Please list any groups, organizations or businesses that you could serve as a liaison to on behalf of The Shelter.
Please tell us anything else you’d like to share.