Shepherd’s LightHouse, Inc.
Prospective Board Member Application
Date:______________
Name:_______________________________________ Birth Date: _________________
Address: ________________________________________________________________
City:
E-mail address: ___________________________________________________________
Spouse’s First Name: ______________________________________________________
High School: _______________________________________ Year Graduated: ________
College: ________________________________________ Degree: _________________
Other Educational Experience: ______________________________________________
Occupation (If retired give last occupation)_____________________________________
Company name: __________________________________________________________
Church or synagogue affiliation: _____________________________________________
How long have you been a member?:__________________________________________
Please list the positions and various religious volunteer responsibilities you have been involved in:
Please list Current and last employer:
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Civic Activities:
Please list any additional civic activities and affiliations.
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Please list your area of expertise:
Please give a short statement reflecting why you are interested in serving on the board of Directors:
List any other boards that you are currently serving on:
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Who or what organization is nominating you for Board Membership?
Any other comments:
I understand that the Board will review this application:
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Sign Date
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Print Date