Virginia Hemophilia Foundation/VHF Board of Directors Interest Form

PERSONAL INFORMATION

Name *

First

Middle

Last

Salutation:

If you answered other, please list here:

Preferred Pronouns:

He/Him/His
She/Her/Hers
They/Them/Theirs
Other

If you answered other, please list here:

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Personal Email *

EMPLOYMENT INFORMATION

Place of Employment *

Job Title/Description *

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you prefer mail be sent to: *

Home Address
Business Address
Other

If you answered other, please list here:

Business Phone *

Business Email

EDUCATIONAL BACKGROUND

College/University

Major/Degree and Year Graduated

College/University

Major/Degree and Year Graduated

Trainings or Certifications

MEMBERSHIPS

Professional Organizations

Service/Social Clubs

Please list any community service or related awards you have received:

REFERENCES

References: Please list two people, not related to you who have knowledge of your qualifications *

First

Last

Phone *

Email *

Relationship to Applicant

First

Last

Phone *

Email *

*

Relationship to Applicant

Some positions and roles require a criminal background check. If needed, would you consent to such a check? *

Yes
No

Have you ever been convicted of a crime, or are you currently under indictment? *

Yes
No

If yes, please explain:

OTHER INFORMATION

Please describe any experience you have had as a community member, donor or volunteer with VHF. How many year(s) have you been involved in some capacity? *

Have you ever been involved with other non-profit organizations as a volunteer leader? If so, please list organizations and type of involvement. *

What do you think are the most important duties of a Board member? *

Why are you interested in serving on this Board? *

Describe how your skills and values will be an asset in serving on this Board. *

Our Board members are expected to attend four Board meetings each year, with several being in-person, as well as participate in regular conference calls, and attend a majority of special events. Will your schedule allow this level of participation? Are there times each month/year that you would not be available for meetings? *

Board members are asked to join one or more committees. If you become a part of the VHF Board, which areas of interest do you have based on your personal and professional skills? *

Please explain your choices: *

Any additional information you feel would be helpful to share?

I confirm that all the information presented to the Foundation is accurate, true, and complete. If selected for the Board of Directors, I agree to adhere to all Foundation policies, guidelines, and values. I agree to a criminal background check if required for my position and role, and agree to report any criminal indictments or convictions which may occur during my time on the Board. *

Yes, I confirm and agree.

Date / Time *

Date

Time

Virginia Hemophilia Foundation/VHF Board of Directors Interest Form

PERSONAL INFORMATION

EMPLOYMENT INFORMATION

EDUCATIONAL BACKGROUND

MEMBERSHIPS

REFERENCES

OTHER INFORMATION

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