LeadUS Mentoring Program 2015-16

Board of Directors Application
Date:

MonthDayYear
Date
Hour MinutesAM/PM Option
Which Board of Director position are you interested in?*

President of the BoardVice President of the BoardTreasurer of the BoardSecretary of the BoardDirector of Fundraising and EventsExecutive Director
Who invited you to apply?*

Mr. Eddie RossMs. Bran-Dee JelksMs. Shantasha LoveMs. Keshee DentName not listed
Personal Information
Full Name:*

Last NameFirst Name
Email:*
example@example.com
Phone Number:*
Date of Birth: *

MonthDayYear
Date
Social Security Number: *
Preferred Pronouns:*

She/Her/HersHe/Him/HisThey/Them/Their
Number of Children:*

1234+
Religious Preference: *
Highest Level of Education: *
Marital Status: *
Wedding Anniversary:*

MonthDayYear
Date
Spouse Name: *

First NameLast Name
What area do you live?*

Saint Louis City, MOSaint Louis County, MOOut of State Applicant
Are you registered to vote?*

YesNoPrefer not to say
Are you a United States Citizen?*

YesNo
Gender Identity:*

MaleFemaleOther
Do you have a disability?*

YesNoPrefer not to say
Are you a survivor of DV?*

YesNoPrefer not to say
Any medical disclosures?*

YesNoPrefer not to say
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Birth:*
Ethnicity:*

African American/BlackCaucasian/WhiteHispanic/LatinoAsia/Chinese
Political Party:*

DemocraticRepublicanIndependentLiberalPrefer not to say
Business/Experience/Work Information
Are you currently employed?*

YesNot at this time
Current Title/Profession:*
Current Employer:*
Work Email: *
example@example.com
Work Phone: *
Please enter a valid phone number.
Can we send a reference check to your employer?*

YesNo
Supervisor's Name: *
Supervisor's Email:*
example@example.com
Are you, or have you ever been a member of the armed forces of the United States? If so, please list dates of service, branch of service, rank and type of discharge.*

YesNo
List dates of service, branch of service, rank and type of discharge.*
Do you currently hold, or have you previously held, any local, state or federal government positions, appointments or elected officials.*

YesNo
List any current/previously held, any local, state or federal government positions, appointments or elected officials.*
Do you currently hold any professional licenses or certificates? Do you hold any that are not limited to Missouri?*

YesNo
List any professional licenses and/or certificates. *
Are you currently involved in any significant community and professional associations?*

YesNo
List any current associations and/or affiliations? (include your title, if possible)*
Do you hold any higher education degrees? (Provide school, degree, and subject of concentration)*

YesNo
List the school(s), degree(s), and subject of concentration.*
Do you, or does anyone in your family, have any contracts with St. Louis City and/or St. Louis County (or have an ownership in any entity or group which has a contract with the St. Louis City and/or St. Louis County), for the performance of any services, provision of any goods; or the sale or lease of any property?*

YesNo
Please explain. *
Do you have any financial or other interest that might present a conflict of interest, or the appearance of such a conflict, if you were appointed to the position for which you have applied?*

YesNo
Please explain. *
Emergency Contact Person:*
Emergency Relation:*
Emergency Contact Phone Number:*
Please enter a valid phone number.
Emergency Contact Email:*
example@example.com
After your application has been reviewed, you will be scheduled for an interview to discuss expectations and answer any additional questions. Thank you for your interest.

I certify, by my signature, that the information contained within this application and all supporting documents is true, accurate, and complete to the best of my knowledge. An electronic signature is accepted.
Signature*

Clear
Should be Empty:

Board of Directors Application

Personal Information

Business/Experience/Work Information