CASA Board Member Application

Maryland CASA Association

Prospective Board Member Application
Full Name:*

PrefixFirst NameLast NameSuffix
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home/Cell Phone Number:*
E-mail Address:*
How did you learn about Maryland CASA?*
What is your primary motivation for joining the Maryland CASA Board of Directors?:*
Professional Information
Employer:*
Job Title:*
Occupation/Industry:*
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone:

Area CodePhone Number
Work Fax:

Area CodePhone Number
Work E-mail (if different than above):
I preferred to be contacted at:*

HomeWork
Background Informaton
Educational Background: *
Organizations and Associations to which you belong:
Brief Biographical Summary:*
Please Attach Resume:*

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Additional Information
Spouse's Name:

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Spouse's Employer:
Spouse's Occupation
Areas of Interest
I will assist Maryland CASA Association in the following areas:*

Board MembershipFundraisingProgram Development/EvaluationPublic Awareness/Volunteer RecruitmentCorporate RelationsLegislative RelationsFinanceStrategic PlanningPolicy DevelopmentRisk MangementOther
Commitments
Commitments (must agree to all):*

I agree to attend at least 75% of all meetings of the Maryland CASA Association, including meetings of committees to which I am assigned.I agree to actively support Maryland CASA Association's fundraising efforts, including a personal financial commitment of at least $50 per month ($600 per year).I have not been arrested and/or convicted of a violation of any federal, state, county or municipal law, regulation or ordinance, with the exception of motor vehicle offenses with a fine of $50 or less. If yes, please explain below. (Board applicants must undergo a criminal background check prior to appointment to the board.)I have not been the subject of an allegation of child abuse or neglect in Maryland or any other state or country. (A child abuse registry check will be conducted on all board applicants.)
Explanation (ignore if not applicable):
References

* Please include both personal and professional references. *
Reference 1: *

Professional ReferencePersonal Reference
Reference 1 Name:*
Reference 1 Relationship to you:*
Reference 1 Phone Number:*

Area CodePhone Number
Reference 1 E-mail:*
Reference 2: *

Professional ReferencePersonal Reference
Reference 2 Name:*
Reference 2 Relationship to you:*
Reference 2 Phone Number:*

Area CodePhone Number
Reference 2 Email:*
Reference 3: *

Professional ReferencePersonal Reference
Reference 3 Name:*
Reference 3 Relationship to you:*
Reference 3 Phone Number:*

Area CodePhone Number
Reference 3 Email:*
Signature

* By signing your name in the box below, you certify that all information provided in this application is true and complete and consent to background checks mentioned above. *
Please sign:*
Date:*

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Maryland CASA Association