Application
Application/Nomination for USSI Board of Directors
Name (Please Print)_________________________________________________________________________
Address____________________________________________________________________________________
______________________________________________________________________________________________
Phone ________________________________________________________________________________________
Email address ________________________________________________________________________________
Are you available to devote 10-12 hours per month to Board activities, including Board and committee meetings? ____Yes ____No
What talents do you feel you can contribute to the Board?
______________________________________________________________________________________________________
Why are you interested in serving on the USSI Board of Directors?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
What other non-profit board have you served (please include dates)?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Are you currently serving on a non-profit Board? ____yes ___no
If yes, which one __________________________________________________________________________________
______________________________________________________________________________________________________
Can we contact them about your Board service? _______ Yes ______No
Please list three references
Name ______________________________________________________________________________________
Address_____________________________________________________________________________________
Phone ___________________________________________
Name _________________________________________________________________________________________
Address ________________________________________________________________________________________
Phone ________________________________________________
Name ____________________________________________________________________________________________
Address ___________________________________________________________________________________________
Phone ________________________________________________________________________________
Thank you for your interest in serving on the Upper Susitna Community/Senior Center Board of Directors
___________________________________________________________ ___________________
Signature Date
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USSI Executive Committee Use Only
______ Nominee has had a personal meeting with a member of the Board
______ Nominee application reviewed by committee Date __________
_____ Nominee has attended a Board meeting Date _________
______ Nominee was interviewed by committee Date ___________
Recommended for election/appointment to the Board Of Directors
________ Yes ______No Comments:
9/6/2017 - USSI