ASSE Foundation Prospective Board Member Information Sheet
Q.1
Name
Title
First Name
Last Name
Q.2
Organization
Q.3
Address
Address Line 1
Address Line 2
City
State
Zip Code
Q.4
Telephone(day)
(e.g. 1 201-234-5678)
Q.5
Telephone(evening)
(e.g. 1 201-234-5678)
Q.6
Telephone(mobile)
(e.g. 1 201-234-5678)
Q.7
Email
(e.g. john@example.com)
Q.8
Source of referral
Q.9
Special skills
Fundraising
Personnel/Human Resources
Finances
Business
Marketing/Public Relations
Technology
Legal
Other:
Q.10
Current industry in which you work
Insurance
Manufacturing
Service
Technology
Construction
Transportation
Energy
Academia/Research □ Vendor
Consultant
Other:
Q.11
Other industries in which you have experience
Insurance
Manufacturing
Service
Technology
Construction
Transportation
Energy
Academia/Research □ Vendor
Consultant
Other:
Q.12
Professional background
For-profit business
Government
Nonprofit organization
Other:
Q.13
Previous ASSE involvement (Length of membership, committees served on, scholarship/grant recipient, etc)
Q.14
Certifications
Q.15
Other affiliations
Q.16
Other board service
Q.17
Foundation Donation History
Q.18
Other pertinent information