Contact Information Name* First Last Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Email* Employer Information Company Name Job Title Type of Organization Primary service(s) and area/population servedWork Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Email Preferred method of contact Work Residence Interests Skills, experience and interests(Please select all that apply) Select All Finance, accounting Education, instruction Personnel, human resources Special Events, event planning Administration, management Grant writing Nonprofit experience Fundraising Community service Outreach, advocacy Policy development Program evaluation Public relations, communications Committee involvement Please list boards and committees that you serve on, or have served on(business, civic, community, fraternal, political, professional, recreational, religious, and social). Please include: Organization, Role/Title, and Dates of Service Special Skills or Qualifications/ Education, Training, Certificates Summarize special skills, qualifications and education Board of Director Participation Are you able to commit to 2-3 hours per/month for meetings and volunteer commitments? Yes No Maybe How do you feel Wishbone Foundation would benefit from your involvement on the Board of Directors?Please list any groups, organizations or businesses that you could serve as a liaison to on behalf of Wishbone Foundation.Please tell us anything else you’d like to share.Agreement*By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a board member, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. I AgreeName First Last Our Policy It is the policy of Wishbone Foundation to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Thank you for completing this application form and for your interest in Wishbone Foundation. CAPTCHANameThis field is for validation purposes and should be left unchanged. 43332
