1.Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

2.Preferred method of contact

Phone

Email

3.If employed, please share about your employer

4.Please list boards and committees that you serve on, or
have served on. (Business, civic, fraternal, political,
professional, recreational, religious, social)

Please include: Organization/Committee, Role/Title, and Dates of
Service MM/YY - MM/YY for each

5.Please select any skills, experience, and interests that you
would bring to the Board of Directors (Please check all that
apply)

Lived Experience with a disability

Marketing/Communications

Fundraising

Accounting/Finance

Grant Writing

Familiarity with Independent Living Centers (Like Access to Ind)

Leadership

Advocacy

Other

6.Please share any awards or honors that you'd like to
mention.

7.Please share any education/training/certificates you have

8.Please share any education/training/certificates you have