Inland NW Council Member Application Form

Name(Required)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Business Phone(Required)

Cell Phone(Required)

Email(Required)

Current Position/Company(Required)

Why do you want to serve on the Inland Northwest Lighthouse Advisory Council?

What specific strengths and skills do you bring to the council?

Have you served on other nonprofit boards or councils?

Yes

If yes, which ones and in what capacity?

How much time will you be able to commit to council activities per month?

What other organizations in the community are you a member of?

What is your experience raising funds or in donor relations?

What is your experience in public relations or community relations?

Here are some opportunities to raise funds for Inland Northwest Lighthouse. Which are you willing to participate in?

Make a significant personal contribution

Ask friends/associates to contribute

Participate in the Lighthouse Food Truck Rally and other events

Any of the above

Other

If other, please elaborate:

Do you have experience working or socializing in the blind and/or DeafBlind communities?

Yes

If yes, which ones and in what capacity and/or context?

How do you think you can help The Lighthouse for the Blind, Inc. in fulfilling its mission of creating and enhancing opportunities for independence and self-sufficiency of people who are blind, DeafBlind, and blind with other disabilities?

Do you feel that there is any potential for a conflict of interest as a board member?

Yes

If yes, please explain.

Experience & Expertise

What would you say are your top 3 areas of experience/expertise? Please explain in as much detail as possible.

Area of Expertise #1

Area of Expertise #2

Area of Expertise #3

What can we do to ensure that your participation is meaningful, fulfilling and rewarding?

Name

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