July 22, 2017

Apply Online to become a Board Member!

Board of Director’s Application

Personal Information

Please fill out each field completely.
Name
First Last
Address
Street Address
Address Line 2
City State / Province / Region
Postal / Zip Code Country
Phone Number
### ### ####
Email

Board Applicant Information

Please fill out each field completely
I am from Region

Have you ever been a representative/alternate on
the Board of Directors for People First of
Louisiana
YES
NO

Are you a graduate of Partners in Policy Making?
Yes
No

Will you have support to attend and participate in
the People First of Louisiana Board
meetings/trainings?
Yes
No

If you answered NO to the previous question please
explain what assistance you will need. (example:
Travel to and from meetings, support during the
meetings, etc)

Have you read the People First of Louisiana
Mission Statement?
Yes
No

Do you agree with the Poeple First of Louisiana
Mission State
Yes
No
I haven’t read it

Explain your answer above

Have you read the People First of Louisiana Vision
Statement
Yes
No

Do you agree with the People First of Louisiana
Vision Statement?
Yes
No
I haven’t read it

Explain your answer above

Advocacy Experience

Advocacy mean to actively support an idea or cause
Please list any past and current advocacy
experience

Are you a member of People First of Louisiana?
yes
no
Please list any other advocacy organizations here:

References

Please list name and contact information of 2 people that know of your advocacy activities. Also, list the name and contact information of a friend or family member.
Reference 1
First Last
Home Phone
### ### ####
Cell Phone
### ### ####
Email

When is the best time to contact this person

Reference 2
First Last
Home Phone
### ### ####
Cell Phone
### ### ####
Email

When is the best time to contact this person

Friend/Family Member
First Last
Home Phone
### ### ####
Cell Phone
### ### ####
Email

When is the best time to contact this person

Acknowledgement Form

I have read People First of Louisiana Board of Directors “Position and Responsibilities”. I agree to fulfill the reposnsibilitiesto the best of my ability and represent People First of Louisiana as a leader in building self-advocacy in Louisiana.
Electronic Signature

Date
MM / DD / YYYY
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