About Care Board of Director Application

Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Name of Employer *

Position *

Brief Biography *

What other organizations are you currently involved with and in what capacity? *

Are you willing to contribute expertise in the following areas: *

*You may check one or multiple boxes.

If you selected Other, please explain.

Are you willing to financially support About Care in the amount of $600 to $1200 annually through any or all of the following avenues: *

*You may check one or all boxes.

I hereby apply for a seat on the About Care Board of Directors. *

Date / Time *

Date

Time