Board Application

Personal Information

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* Name

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* Business/Organization Name

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* Your Title

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* Number of Employees

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* Organization/Company Address

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* Organization/Company Website

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* Work Phone Number

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* Cell Phone Number

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* Email Address

Business/Organization Operations

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* Does your business/organization operate within Lane County:

Yes

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* Board Representation for which you are applying (Select One):

Business/Private Industry (Category 1)

Labor (representative of labor organization) (Category 2)

Labor (rep of a joint labor-management, or union affiliated, registered apprenticeship program) (Category 2)

Community-Based Organization (Category 2)

Youth Training, Youth Employment, or Youth Education (Category 2)

Adult Education (Category 3)

Economic and Community Development (Category 4)

Wagner-Peyser (Category 4)

Vocational Rehabilitation (Category 4)

Administering programs related to transportation, housing, and public assistance (Category 4)

Philanthropic Organization (Category 4)

Complete Category 1, 2, 3, or 4 below based on the board representation checked above.

CATEGORY 1: BUSINESS SECTOR REPRESENTATION

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* Authority (Select One):

I hold optimum policy-making authority.

I hold optimum hiring authority.

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* Role (Select One):

Business Owner

Business Chief Executive Officer or Chief Operating Officer

Other

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* If "Other" is checked, please describe your policy-making and/or hiring authority.

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* Business Type:

Private Sector Large/For-Profit Business (500+ employees)

Private Sector Small/For-Profit Business (less than 500 employees)

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* Describe the industry or occupation represented by your business:

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* Nominating Organization (chamber/association or business trade association):

CATEGORY 2: WORKFORCE REPRESENTATIVE

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* Representation (Select One):

Labor Organization

Registered Apprenticeship Program (Joint Labor-Management or Union-Affiliated)

Community-Based Organization (CBO) addressing employment needs of individuals with barriers to employment, including organizations that serve veterans or that provide or support competitive integrated employment for individuals with disabilities.

Youth Training, Youth Employment, or Youth Education Organization

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* Nominating Organization:

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* If you selected Community-Based Organization above, describe your experience addressing employment, training, and education needs to those with barriers to employment.

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* If you selected Youth Training, Youth Employment, or Youth Education Organization above, describe your experience addressing training, employment, and education for in -school and/or out-of-school youth.

CATEGORY 3: EDUCATION REPRESENTATIVE

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* Representation (Select One):

Adult Education and Literacy Provider under Title II

Higher Education providing workforce development activities (including community colleges)

CATEGORY 4: ECONOMIC DEVELOPMENT/WAGNER PEYSER/VOC REHABILITATION REPRESENTATIVE/TRANSPORTATION, HOUSING, PUBLIC ASSISTANCE/PHILANTHROPIC

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* Representation (Select One):

Economic and Community Development Entity

Wagner-Peyser

Vocational Rehabilitation

Administering programs relating to transportation, housing, and public assistance

Philanthropic organization

All applicants are required to complete the following two questions.

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* Why do you wish to serve on the Lane Workforce Partnership Board of Directors?

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* Please tell us about any other boards or organizations of which you are an active member.

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* Signature (please type your name)

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* Date (please enter date completed)

Date

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100% of survey complete.