Board of Directors Application
2207 N. 2nd St., Milwaukee, WI 53212
(414) 372-1550 x 105
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Business Number
Email
example@example.com
Why are you interested in serving on the Board of HeartLove Place?
What is your vision or goal for serving on the Board of Directors?
State / Province
Postal / Zip Code
Please share your current church affiliation and your relationship with Jesus Christ..
Areas of expertise/contributions you feel you could make to HeartLove Place
City
State / Province
Other volunteer commitments:
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for applying to the Board of Directors.
Summarize any additional information...
Summarize any additional information...
State / Province
Summarize any additional information...
WORK EXPERIENCE (RESUME MAY BE ATTACHED)
Job Title | Company Name
Company Address
City | State
Zip Code
Company Phone Number
WORK EXPERIENCE (RESUME MAY BE ATTACHED)
Job Title | Company Name
Company Address
City | State
Zip Code
Company Phone Number
EDUCATION
COLLEGE
DEGREE
YEAR EARNED
State / Province
Postal / Zip Code
Please provide 3 references. One must be from your Pastor, the other two from non relatives who have a definite knowledge of your qualifications and ability to serve on the Board of Directors.
Reference 1
Name
Address
City | State
Zip Code
Phone Number | Email
Reference 2
Name
Address
City | State
Zip Code
Phone Number | Email
Reference 3
Name
Address
City | State
Zip Code
Phone Number | Email
Completed Background Check Form
References
Meeting with Executive Director Date
CERTIFICATION AND RELEASE:
I certify that every statement made in this application for service with HeartLove Place Inc., is true and complete to the best of my knowledge and beliefs. Each statement is made in good faith. I hereby request organizations and individuals having knowledge about me to provide HeartLove Place Inc., with the service related information necessary to accurately evaluate my application. I also release the source of information from any liability or damage whatsoever which may be a result of providing the requested information.
Signature
Date:__________________________________________________
(Office Use | Attach Letter from Board Chair)
Board Review
Nominee voted on
Outcome: Approved | Not Approved
Date Nominee Invited to be a Board Member
Submit Form
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