Board Member Application Step 1 of 4 25% Senior Connection Board Member Position DescriptionAcknowledgement(Required) I have read the term and participation expectations and the board member responsibilities.Name(Required) First Middle Last Cell Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Other languages spoken (including sign language)(Required)How did you learn about Senior Connection?(Required)Brief Bio(Required)TWO PARAGRAPH MAXIMUMWhich of the following fields do you have experience in? Check all boxes that apply.(Required) Finance/Accounting Fundraising HR Legal Marketing/Social Media Local Government & Advocacy Other Other(Required) Please describe your experience and how this would serve the mission of the organization.(Required)TWO PARAGRAPH MAXIMUMPlease describe any previous or current experience with nonprofit boards(Required)TWO PARAGRAPH MAXIMUMPlease list any degrees, licenses, certifications or other designations(Required)TWO PARAGRAPH MAXIMUM If approved for the board, the following information is necessary to run a background check.Date of birth(Required) MM slash DD slash YYYY Gender(Required)What date did you move into your home(Required) MM slash DD slash YYYY I hereby certify that all information I have supplied in this volunteer application is true, complete, and accurate. I understand that by submitting this application, I authorize inquiries to be made concerning my suitability as a volunteer and that this application is not a guarantee that I will be accepted as a volunteer with The Senior Connection. I also give permission for criminal background, three year MVA driving record check and other checks, if applicable. Further, I acknowledge that participation in any Senior Connection program as a volunteer does not constitute employment with The Senior Connection and that I am not covered by any type of Workers’ Compensation program while performing duties associated with volunteering. I understand that The Senior Connection does not unlawfully discriminate in employment or volunteer appointments and no question on this application is used for the purpose of limiting or excusing any applicant from consideration on a basis prohibited by applicable local, state, or federal law. I agree to comply with and be bound by the agency’s safety and health rules and regulations, rules of conduct, and any other policy and/or rule or procedure set forth by the organization.Signature(Required)CAPTCHAPost Custom Field Δ