Please fill out the following information as soon as possible. It should take you approximately 8 minutes to complete. Information will be kept confidential and only used with your permission.  When preparing our annotated board list, we will limit the information on that list to your professional affiliation.  For internal purposes we will prepare a board list that includes name, contact numbers, email, and preferred address(es).  This is helpful information as I seek out potential donors and grant opportunities.  Thank you!

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* 1. Preferred salutation:

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* 2. What is your name (First & Last)?

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* 3. What is your mobile (cell) phone number?

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* 4. What is your home phone number?

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* 5. What is your home mailing address?

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* 6. What is your race?

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* 7. What is your ethnicity?

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* 8. Who is your Employer?

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* 9. What is your Title or Occupation?

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* 10. What is your Office Address?

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* 11. What is your Office Phone Number?

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* 12. What is your Office Fax Number?

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* 13. What is your Spouse/Partner's Name?

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* 14. What is your Spouse/Partner's Occupation?

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* 15. Children and their ages?

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* 16. Your Education: (State degree(s) and college(s)/university(ies) attended)

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* 17. What is your 2019 CoH Board position?

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* 18. Other Boards you are currently serving:

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* 19. Other Boards on which you have previously served:

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* 20. Committees you are interested in serving:

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* 21. Other interest areas, hobbies, and skills that might be interesting for us to know about and might connect with a volunteer or funding opportunity.

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* 22. Any other information you want to share.

0 of 22 answered
 

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