Board Member Application

Name

First Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone

Are you able to commit 2-3 hours per month to serving on the baord?

I have expertise in:

If *Other* was selected in the previous question, please specify:

I have influence and/or contact within the:

If *Other* was selected in the previous question, please specify:

Please describe the area(s) of expertise/contribution you feel you can make to further the mission of substance abuse prevention.

Please list prior (if any) experience serving as a Board member for other non-profit organizations.

What made you choose The Prevention Council as a potential board member

Please share any other information you feel important for consideration of your application to serve as a Board member.

Consent*

I confirm the information provided above.

MISSION STATEMENT