*1.Personal Information:(Required.)

Full Name:

Address:

Phone Number:

Email Address:

*2.Professional Background:(Required.)

Current Job Title:

Employer:

Years of Experience as In-house Attorney:

*3.Previous Relevant Experience:(Required.)

Position:

Organization:

Duration:

Responsibilities:

Skills and Expertise:

*4.Areas of Legal Expertise: (e.g., Mergers & Acquisitions, Corporate Governance, Compliance, Intellectual Property, etc.)(Required.)

*5.Relevant Skills: (e.g., Strategic Planning, Leadership, Advocacy, Community Engagement, etc.)(Required.)

*6.Motivation and Commitment:(Required.)

Why are you interested in joining the board of the Association of Corporate Counsel, Northeast Chapter?

What unique perspectives or contributions can you bring to the organization?

Please provide a brief biographical summary of yourself.

If a Board position is not available, would you be interested in serving on any Chapter Committees and, if so, which ones in particular? (e.g., Communications, DEI, Membership, NextGen, Pro Bono/Community Service, Programming, Women's)

*7.Memberships in Legal Associations:(Required.)

*8.Reference 1:(Required.)

Name:

Relationship:

Contact Information:

*9.Reference 2:(Required.)

Name:

Relationship:

Contact Information:

10.Signature:

Applicant's Signature:

Date: