DRA Board of Directors Application

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) ______________________________________

1. 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:

1. What experience have you had with people with disabilities and/or with families of people with disabilities?

__________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What experiences have you had serving on community boards or committees?

__________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Would you commit to attend quarterly board meetings of approximately three hours?  (Mileage would be paid)  Yes        ____    No       _____

4. What is your major interest in serving as a Disability Rights Arkansas board member?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

5. 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

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