Board of Directors Membership Application

Thank you for expressing an interest in serving as a volunteer member of Northwest Wisconsin Community Services Inc. (NWCSA) Board of Directors.

All board members are expected to actively participate in board meetings, fund raising activities, and other related meeting/activities. Their commitment, professionalism, and high ethical standards are vital to the stability and future of NWCSA, and the population served.

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* 1. Name: (Last Name, First Name, Middle Name)

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* 2. Address

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Have you ever been convicted of any felony crime?

Yes

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* 4. If yes to question 8, when, where and what is the disposition of the case? (a conviction will not be an absolute bar of consideration).

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* 5. First Organization Address

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Volunteer/Board History Section.
In the areas below, please list professional trade, business or civic organizations and any offices held, beginning with the most current and answer the questions that follow. If you need additional space for information, please email your list to mrounsville@northwest-csa.org. (Exclude memberships that would reveal sex, race, religion, national origin, age, ancestry, or other protected status.)

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* 6. From

Date

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* 7. To

Date

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* 8. Office Held

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* 9. Duties included

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* 10. Reason for Leaving

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* 11. Second Organization Address

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 12. From

Date

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* 13. To

Date

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* 14. Office Held

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* 15. Duties included

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* 16. Reason for Leaving

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* 17. Third Organization Address

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 18. From

Date

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* 19. To

Date

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* 20. Office Held

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* 21. Duties included

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* 22. Reason for Leaving

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* 23. Fourth Organization Address

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 24. From

Date

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* 25. To

Date

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* 26. Office Held

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* 27. Duties included

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* 28. Reason for Leaving

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* 29. What were your major accomplishments on boards and/or offices held in which you have participated in?

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* 30. What do you believe to be your role as a board member?

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* 31. What contributions do you believe you could make as a board member for NWCSA?

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* 32. Why do you wish to serve as a board member for NWCSA?

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* 33. Meetings are generally held the second Friday of every other month over Zoom from 10:00 am to 12:00 pm. Would this be a conflict with your schedule?

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* 34. Describe any specialized training, apprenticeships, skills, or any additional information you feel may be helpful to us in considering your application.

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* 35. List the name, address, and telephone number of three references that are not related to you.

Name, Address, Phone Number, Occupation

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* 36. Please Read Carefully! I certify that all of the information provided by me in this Board Member Application (or any other accompanying or required documents) is correct, accurate, and complete to the best of my knowledge. I understand that submission of this form does not guarantee acceptance onto the Board of Directors. I hereby authorize the Agency and/or its assigns its assigns to investigate my personal history and to obtain any information they have concerning me. Please sign your name and date it.