Back to Natives Board Nominee Application Form

Full Name *

First Name Middle Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number *

- Area Code Phone Number

E-mail* *

Current Employer

Name of Current Employer or NONE if not Employed

Position

May We Contact?

Yes No

Start Date

- Month - Day Year

Skills

List any relevant skills

Qualifications

List any relevant certifications or qualifications

High School

Name of High School Attended

Number of Years Attended

Graduated?

Yes

College

Name of College/University Attended

Number of Years Attended

Graduated?

Yes

Area of Study/Degree

Graduate School

Name of Graduate School Attended

Number of Years Attended

Graduated?

Yes

Area of Study/Degree

Trade School/Other

Name of Trade/Technical/Other School Attended

Number of Years Attended

Graduated?

Yes

Area of Study/Degree

Why are you interested in serving as a Board Member for BTN ?

Area(s) of expertise/Contribution you feel you can make to BTN

How do you feel BTN would benefit from your involvement on the Board of Directors?

Please list any groups, organizations or businesses that you could serve as a liaison on behalf of BTN

Please list boards and committees that you serve or have served on (nonprofit, for-profit business, civic, community, fraternal, political, professional, recreational, religious, and social). Include Organization, Role/Title and Dates of Service.

Other volunteer commitments you currently have.

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

Reference 1

Name of Reference

Relationship

Years Acquainted

Phone

Email

Reference 2

Name of Reference

Relationship

Years Acquainted

Phone

Email

Reference 3

Name of Reference

Relationship

Years Acquainted

Phone

Email

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.)

Yes No

Please review and respond to the following questions.

Are you aware of any information about yourself, which might tend to reflect unfavorably on your reputation, morals, character or ability as a board member for BTN?

Yes No

If yes please explain.

Have You served or volunteered at BTN Before?

Yes No

If yes please explain.

Have You Applied to be a BTN Board Member Before?

Yes No

If yes please explain.

Have you ever been convicted of a felony? (This will not necessarily affect your application.)

Yes No

If yes please explain.

Have You ever been convicted of a controlled substance offense? (This will not necessarily affect your application.)

Yes No

If yes please explain.

Have You ever been convicted of a sex-related crime?

Yes No

If yes please explain.

Are you willing and able to attend BTN Board Meetings?

Yes No

Are you willing to interact with BTN supporters, donors, volunteers, Advisory Council Members and fellow Board Members with professionalism and respect?

Yes No

Are you willing to uphold the responsibilities assigned to you?

Yes No

Cover Letter

Resume

By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected, or if elected and this is discovered, may be removed by a majority vote of the Board.

In consideration of my service, I agree to conform to BTN's rules and governance.

I also understand and agree that the terms and conditions of my service may be changed, by a majority vote of the Board.

Additionally, my signature represents my agreement to the following statements: I understand and agree to the Back to Natives Restoration Board of Directors Expectations; I agree to participate pursuant to the Policies, Procedures and Bylaws of the Back to Natives Restoration Board; and I understand that if conflicts prevent me from performing the rules and expectations as a Board Member, I may be removed from the Board by a majority vote. I understand a Background Check may be required if I am successfully elected to the BTN Board of Directors.

Back to Natives Prospective Board Member Nominee Application

Current Employment:

Relevant Skills/Qualifications and/or Employment (attach resume if relevant):

Education:

References:

Cover Letter & Resume (Optional):

Send Application: