NOBLE SQUIRES ORGANIZATION

NOBLE SQUIRES ORGANIZATION

BOARD MEMBER APPLICATION

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First Name MI Last Name Home Phone

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Street Address Town State Zip Code Cell Phone (optional)

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Email Address

Position for which you are applying: ____________________________________________________________

Please list any experience you have had working in any organization or group, including dates, locations, and responsibilities:

__________________________________________________________________________________________

_____________________________________________________________________________

Please list any skills, background, job experiences you have which you feel might benefit the organization:

_____________________________________________________________________________

The following questions must be answered (circle YES or NO):

- Have you ever been convicted or are currently charged with child abuse or neglect? YES NO

- Have you ever been dismissed from any youth organization for improper conduct? YES NO

- Have you ever been convicted of a crime involving money, funds, or fraud? YES NO

- Is there any other circumstance which would call into question you being entrusted

with the supervision of young people or participation as a board member? Explain. YES NO

_____________________________________________________________________________

List three character references, with no more than one being a close family member. References would preferably have knowledge of your dealings and interactions with youths.

Name: _________________________________________________ Phone: _______________

I understand that the information I have provided may be verified and the references listed may be contacted. In signing this application I confirm that the information I have given is true and correct.

Signature: _____________________________________________ Date: _________________