DISABILITY RIGHTS ARKANSAS
BOARD OF DIRECTORS APPLICATION
(You may add more pages as necessary)
Name________________________________________Date____________________
Address _____________________________________________________________
City _______________________________ Zip__________
Phone (h)_________________ (w)__________________ (cell)________________
E-mail_____________________________________Fax_____________________
Occupation_________________________________________________________
Agency or Company (if applicable) ______________________________________
- In order to achieve diversity of the Board of Directors, we would appreciate your response to the following:
Male Female Date of Birth: _______________
How would you describe yourself?
_____ Asian
_____ Black, not of Hispanic/Latino origin
_____ Hispanic
_____ Multicultural (Identified with more than one of the above)
_____ North American Indian or Alaskan Native
_____ Pacific Islander
_____ White, not of Hispanic/Latino origin
_____ Other than above:
Do you have a disability? Yes _____ No _____
If yes, please specify disability? ____________________________________________
Are you a parent of an individual with a disability? Yes _____ No _____
If yes, please specify disability and age of individual _______________________________ _________________________ __ ____________________________________________________
III. Experience:
- What experience have you had with people with disabilities and/or with families of people with disabilities?
__________________________________________________________________________________________________________________________________________________________________________________________________________________
- What experiences have you had serving on community boards or committees?
__________________________________________________________________________________________________________________________________________________________________________________________________________________
- Would you commit to attend quarterly board meetings of approximately three hours? (Mileage would be paid) Yes ____ No _____
- What is your major interest in serving as a Disability Rights Arkansas board member?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
- Why do you think you are a good candidate for this board? ____________________
______________________________________________________________________
________________________________________________________________________________
____________________________________________________________
Please return the completed application and a copy of your resume to:
Disability Rights Arkansas
400 West Capitol Avenue, Suite 1200
Little Rock, AR 72201
(501) 296-1779 fax
tmasseau@www.disabilityrightsar.org.php72-4.lan3-1.websitetestlink.com