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