ASSE Foundation Prospective Board Member Information Sheet

Q.1
Name



Q.2
Organization

Q.3
Address





Q.4
Telephone(day)

Q.5
Telephone(evening)

Q.6
Telephone(mobile)

Q.7
Email

Q.8
Source of referral

Q.9
Special skills

Q.10
Current industry in which you work

Q.11
Other industries in which you have experience

Q.12
Professional background

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