Prospective Board Member Profile

Name *

Street Address *

City *

Zip Code *

Home Phone *

Cell Phone *

Email Address *

Employer / Occupation *

Are you retired? *

Current or last position held: *

Business Address *

Business Phone *

Preferred mailing address: *

Personal Information

Birthday (MM/DD) *

Select age range: *

Ethnicity *

Significant other's name *

How long have you lived in Northern Colorado in years? *

Professional Affiliations: (Please list associations with dates of membership) *

Community Activities: (please list other non-profits and committees with dates of service) *

Interests and hobbies: *

What strengths/passions do you feel you bring t the Board to contribute to the success of the mission of the foundation and the Board of DIrectors? *

Please rank in order your committee preference (1 being the most preferred):