PA Wilds Center Board of Directors Candidate Application

Board of Directors Candidate Application
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Phone
Format: (000) 000-0000.
Personal E-mail
example@example.com
Employer
Business/Organization Name
Your title
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Format: (000) 000-0000.
Work E-mail
example@example.com
Type of business or organization
Primary service(s) and area/population served
Preferred Method of Contact
The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.
Gender
Ethnicity:
Please list boards and committees that you serve on, or have served on (business, civic, community, fraternal, political, professional, recreational, religious, social).
Education/Training/Certificates
Optional – Have you received any awards or honors that you’d like to mention?
How do you feel The PA Wilds Center would benefit from your involvement on the Board?
Skills, experience and interests (Please check all that apply)

Other
Please list any groups, organizations or businesses that you could serve as a liaison to on behalf of The PA Wilds Center.
Please tell us anything else you’d like to share.
Should be Empty:

Board of Directors Candidate Application

Employer