Easterseals Northern California Board of Directors Candidate Form

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* Contact Information

Date

Name

Address

City

State

Zip

Phone

Cell Phone

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* Where do you work?

Organization Name

Address

City

State

Zip

Title or Position

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* Were you referred?

Yes

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* Special Skills (check all that apply)

Fundraising

Technology

Legal

Advocacy

Marketing/Public Relations

Personnel/Human Resources

Finance

Healthcare Management

Other (please specify)

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* Professional Background

For-Profit Business

Government

Non-Profit Organization

Start Up

Other (please specify)

Easterseals Northern California Board of Directors Candidate Form

Question Title

* Contact Information

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* Where do you work?

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* Were you referred?

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* Special Skills (check all that apply)

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* Professional Background

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* Other professional affiliations:

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* Briefly describe your connection to our mission:

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* Please tell us about any previous experience serving on boards.

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* How do you envision contributing to our board?

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* Other important information you think we should know: