Cohort Application - Board Effectiveness & Diversity Cohort - Deadline: Sept. 5, 2018

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* 1. Who are you?

Name

Title

Email

Agency Name

Work Phone

Cell Phone

Agency Budget (est. $)

# Staff

# Board

Length of time you have been with this agency in this position

Length of time you have been employed within the nonprofit sector

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* 2. Agency Mission

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* 3. Date your agency was founded

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* 4. Has your agency merged with any other agencies?

Yes

No

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* 5. If Yes, with whom did you merge and when?

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* 6. Self-Report with brief comments on your current capacity including policies, procedures around board governance, board diversity and practices.

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* 7. Top 3 Challenges you wish to address in this project

# 1

#2

#3

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* 8. Each agency is invited to have a team of 3 representatives comprised of the CEO/ED, board member & a senior staff member. Please list below the name, role, email & phone for each

Board member name

Board member role

Board member email

Board member phone

Sr. staff member name

Sr. staff member title

Sr. staff member email

Sr. staff member phone

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* 9. Please send a copy of your most recent 990 and annual report to pat.knoerle-jordan@experience-on-demand.com. Deadline for this application and submissions is September 5, 2018.

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