This form is designed to help NDANO’s Governance Committee identify potential board member interests and experience and how these talents can benefit NDANO, its membership and the state nonprofit sector.

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* 1. Name:  (Include professional designations, i.e. M.S.W., Ph.D., etc.)

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* 2. Organization Affiliation: (Note if retired)

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* 3. Title/Position:

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* 4. Mailing Address:

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* 5. Phone:

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* 6. Email:

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* 7. Organization Subsector: (Check one - first eight are nonprofit subsectors)

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* 8. Organization Staff Size:

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