NWCSA Northwest Wisconsin Community Services Agency, Inc.

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Thank you for expressing an interest in serving as a volunteer member of Northwest Wisconsin Community Services Agency, Inc. (NWCSA) Board of Directors.

All board members are expected to actively participate in board meetings, fund raising activities and other related meeting/activities. Their commitment, professionalism and high ethical standards are vital to the stability and future of NWCSA and the population served.

General Information Section
In order to be considered as a board member, you must fill in the information below accurately and completely. The information in this packet will be reviewed by the current board members.

Name:
	(Last)	(First)	(Middle)
Home Address		City		State	Zip
Mailing Address		City		State	Zip
Home Phone		Message Phone
Cell Phone		Email

Have you ever been convicted of any felony crime?

Yes No

If “yes”, when, where and what is the disposition of the case?
(A conviction will not be an absolute bar of consideration)

Volunteer/Board History Section
In the areas below, please list professional trade, business or civic organizations and any offices held, beginning with the most current and answer the questions that follow. If you need additional space, attach extra copies of the page needed. (Exclude memberships that would reveal sex, race, religion, national origin, age, ancestry, or other protected status.)

Agency	Phone
Address	City	State	Zip
From	To
Title/Office Held	Contact Name
Duties	Reason for Leaving

Agency	Phone
Address	City	State	Zip
From	To
Title/Office Held	Contact Name
Duties	Reason for Leaving

Agency	Phone
Address	City	State	Zip
From	To
Title/Office Held	Contact Name
Duties	Reason for Leaving

What were your major accomplishments on boards and/or offices held in which you have participated in?	What do you believe to be your role as a board member?


What contributions do you believe you could make as a board member for NWCSA?	Why do you wish to serve as a board member for NWCSA?


Meetings are generally held the second Friday every other month in Ashland from 10:00 am to 12:00 noon. Would this be a conflict with your schedule?

Additional Information
Describe any specialized training, apprenticeship, skills or any additional information you feel may be helpful to us in considering your application.

References
List the name, address and telephone number of three references that are not related to you.

Name	Occupation	Address	Phone #
Name	Occupation	Address	Phone #
Name	Occupation	Address	Phone #

PLEASE READ CAREFULLY!
I certify that all of the information provided by me in this Board Member Application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that submission of this packet does not guarantee acceptance onto the Board of Directors. I hereby authorize the Agency and/or its assigns to investigate my personal history and to obtain any information they have concerning me.