Board of Directors Application
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Membership Application
Name
First
Last
Date
*
MM slash DD slash YYYY
Preferred Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Email
Disability
*
Yes
No
If Yes, Please Select from the following:
*
Physical
Sensory
Cognitive
Other
Race / Ethnicity (required by funders):
*
Leadership Service(s), please list most recent and/or relevant:
Organization
Dates of Service
Contact Name
Explain how ILCKC can benefit from your service as a Board Member:
Referred by:
Δ