Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2010 2011 2012 2013

Salutation: Ms. Mrs. Mr. First Name: Last Name:

Address: City: Province: Select One... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon

Email: Home Phone: Work Phone:

1

In order to assist us in selecting Board members who can best meet the present needs of our organization, would you please provide us with the following information:

Do you live in the area served by Mid-Toronto? Select one... Yes No

Have you volunteered for any agency program? Select one... Yes No
If yes, which program?

Are you a client of any program? Select one... Yes No
If yes, which program?

Are you a senior? Select one... Yes No

Are you currently a member in good standing? Select one... Yes No

Are you currently employed? Select one... Yes No
If yes, what is your occupation?

2

It is important to have Board members who are linked to the many areas of the community. Please indicate below your connections to our community and explain what those connections are:

Business

Public Health

Education

Labour

Social Services

Health Services

Student

Other

3

From time to time, it is useful for Board members to advocate on behalf of client needs. Please tell us below where you feel you can assist:

4

We would like to know what skill(s) you can bring to the Board. Please mark those areas in the boxes below that relate to your skills and tell us what those skills are:

Personnel

Legal

Financial

Planning

Community Relations

Policy Analysis

Fundraising

Other

5

Please tell us why you would like to be a Board member:

6

Would you please provide us with the names of two references whom we can contact:

Reference #1 - (Professional/Character - please no family members)
Name: Phone Number: Relationship:

Reference #2 - (Professional/Character - please no family members)
Name: Phone Number: Relationship:

THANK YOU FOR YOUR INTEREST IN SERVING OUR ORGANIZATION!