Date:
Name:
Mailing Address:
Preferred Phone:
Alternate Phone:
Email Address:
How long have you lived in this area?
Occupation and place of employment: (if applicable)
How did you hear about HAVEN:
Summarize your interest in our organization and mission:
Please describe any previous nonprofit experience or relevant community experience that you may have:
Please rate your experience in the following areas with 5 being highest and 1 being lowest:
Board Development:
1
2
3
4
5
Communication, Public Relations, or Media Relations
1
2
3
4
5
Financial Management:
1
2
3
4
5
Fundraising:
1
2
3
4
5
Human Resources/Organizational Relations:
1
2
3
4
5
Information Technology:
1
2
3
4
5
Leadership:
1
2
3
4
5
Legal:
1
2
3
4
5
Marketing/Branding:
1
2
3
4
5
Professional experience in Sexual Assault, Domestic Violence, and/or Stalking:
1
2
3
4
5
Program Planning and Evaluation:
1
2
3
4
5
Public Speaking:
1
2
3
4
5
Special Events:
1
2
3
4
5
Strategic Planning:
1
2
3
4
5
Other:
1
2
3
4
5
Please elaborate on your three (3) highest rated items above. Please describe how you will utilize these skills and knowledge in your role as a Board Member.
References (Include name, title, relationship/affiliation and all contact information):
1:
2:
3:


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