ICTC PO Box 11923 Portland, OR 97211 (503)460-9324 Board Service Application Date: Name: Address: Phone (home): (work): ____________ Email: __________________________________________________________________ Web-site:________________________________________________________________ Race: (Please check one): ___African American, ____Caucasian, ___Asian, ___Pacific Islander, ____Hispanic, ___Native American, Other ____ Gender: (please check one) ____Male ____Female ____Transgender Education: (please check one): ___High School Diploma, ___Graduate, __Undergraduate, __Doctorate. ICTC 5/24/12 BD 12 Business Owner: ______Yes or ____ No Business Name:__________________________________________________________ Type of Business:_________________________________________________________ How Long in Business:_____________________________________________________ 1. List Previous Board Experience Organization 2. Office or Committee Assignment Date of Service Other Volunteer Service Organization Date of Service Volunteer Capacity Please list character references: Name Email Address Telephone ICTC 5/24/12 BD 12 What strengths will you bring to ICTC? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Are you comfortable fundraising for the ICTC?” __No, ___Yes, ___ Willing to learn. Please share why you desire to be an ICTC Board of Director? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please check hours and days available for volunteering Mon. _____ Tues.____ Wed._____ Thurs. _____ Fri. _____ Sat. ____ Sun. ____ 3. Areas of Education, Training, or Experience Accounting/Finance Board Development Programs Education General Management Public Health Legal Marketing Facilitation Networking Research/Statistics Human Services Fundraising Social Media ICTC 5/24/12 BD 12 4. We anticipate Board service will require at least six to ten hours per month. How much time could you make available for Board activities?__________ ________________________________________________________________ 5. Any other comments? Please attach your CV and/or Resume and forward to ICTC, at ICTC@ictcmidwives.org. ICTC 5/24/12 BD 12
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