Board Member Application

Full Name

Email Address

Phone

Linkedin

Current Occupation/Retired Industry

Relevant Experience (mental health, nonprofits, finance, etc.)

Previous Board or Leadership Experience (if any)

Why are you interested in joining the Board?

How do you see yourself contributing to our mission?

Are you able to commit to quarterly meetings and active participation? Are you able to commit to quarterly meetings and active participation? Yes No

Are you willing to participate in advocacy efforts? Are you willing to participate in advocacy efforts? Yes No

Do you have any potential conflicts of interest? Do you have any potential conflicts of interest? No Yes

If yes, please explain

Full Name

Full Name

Contact

Contact

Relationship

Relationship

Confirmation Confirmation The information provided is accurate and I understand the responsibilities of a Board member at Anchor Point Initiative.

Date