Board of Directors Application Board of Directors Application "*" indicates required fields Applicant InformationI am applying as a* New Applicant Current Board Member (Renewal) Name* First Middle Last Preferred Name (if applicable)Address* Street Address City AlabamaAlaskaAmerican 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 Email Address* Phone Number*Social Security Number*Date of Birth*Professional & Community BackgroundCurrent Occupation / Title*Employer / Organization*Relevant Professional Experience*Community Involvement (in the last 5 years)*Experience*(select all that apply) Nonprofit Management Fundraising & Development Marketing & Communications Legal & Compliance Finance & Accounting Education Disability Services & Advocacy Public Health & Healthcare Government & Policy Community Outreach Other (please specify) Please Specify*Personal or Professional Reference*NameRelationshipEmailPhone Add RemoveMotivation & InterestWhy are you interested in serving on the Board of Directors for ConnectAbility of MN?*Why are you interested in renewing your term for the Board of Directors for ConnectAbility of MN?*Commitment & AvailabilityAre you able to commit to a 1.5 hour meeting once per month?* Yes No Are you able to serve for a three-year term?* Yes No Do you consent to a background check?* Yes No Do you agree to undergo HIPAA Training?* Yes No SignatureI confirm that the information provided is accurate and that I am interested in being considered for the Board of Directors at ConnectAbility of MN.*
