Board Member Application Complete the following form to begin the Board Member application process. You may save your current work and complete the application at a later time. I. PERSONAL INFORMATIONApplicant Name* First Middle Last Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail* Enter Email Confirm Email Email address must be provided to receive a confirmation upon receipt of your application. Allow two weeks from time of submission. II. PROFESSIONAL BACKGROUND AND QUALIFICATIONSOccupation*Employer's Name*Employer's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Education and Training*Certificates and Awards*Other information which may be relevant (Workshops, Professional Memberships, Board Experience)*III. VOLUNTEER EXPERIENCEList volunteer experience and include the name of organization, your position and duties.* IV. REFERENCESPlease list three references (other than relatives).First Reference* First Last Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Email* Occupation*Relationship* Second Reference* First Last Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Email* Occupation*Relationship* Third Reference* First Last Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Email* Occupation*Relationship*V. PERSONAL STATEMENTIn a separate document, state why you are interested in serving as a member of the 3to1 Foundation Board of Directors. Include how your background and experience will contribute to the Board. (Two page limit). Upload the document below.Upload Personal Statement*Accepted file types: jpg, gif, png, pdf. VI. DECLARATION AND ACKNOWLEDGEMENTBy submitting this application to serve on the Board of Directors of the 3to1 Foundation, I understand that the by-laws include certain restrictions and requirements applicable to the directorship of the Board. As a prerequisite to appointment to the Board, I agree to abide by such restrictions and requirements contained in the Foundation’s by-laws as follows: If I am appointed as a Board Director I shall: Become an Annual or Lifetime Member of the 3to1 Foundation Attend all regular board meetings unless excused by the Chairman of the Board Attend the annual board meeting unless excused by the Chairman of the Board Work on at least one 3to1 Foundation committee per year Actively solicit sponsors for 3to1 Foundation events Actively solicit members for the 3to1 Foundation Refrain from speaking on behalf of the 3to1 Foundation unless authorized by the Board Make no attempt, for family members or myself, to profit from any 3to1 contract or expenditure Avoid any real or perceived conflict of interest between my personal interests and 3to1 Foundation interests I further understand that should my application to serve on the Board of Directors of the 3to1 Foundation be accepted and I am appointed to the Board, I will be asked to affirm my agreement to the foregoing as part of my oath of office. I hereby declare that all information contained in this application is true and accurate to the best of my knowledge. I acknowledge that any or all of the content of my application will be kept private and will only be used to determine the status of my application. Should I require additional information regarding the 3to1 Foundation’s Privacy Policy, I will refer the Foundation’s website, www.3to1foundation.org.Signature*VII. APPLICATION SUBMISSIONComplete the application by filling out this last section. Submissions are sent to the BOD committee for review. Contact: Michele Mulholland, 3to1 Foundation Director; michele@3to1foundation.org, 972-764-6524Full Legal Name* First Middle Last Date* Date Format: MM slash DD slash YYYY CAPTCHA
