Application – Independence Associates

Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Gender

How do you identify?

Ethnicity

describe of Phone

Age

Please check all that apply

I am a person with a disability
I am a parent, sibling, or family member of a person with a disability
I am a representative from an organization that provides services for individuals with disabilities

Name of Organization

Please describe your experiences and qualifications to serve on the Board of Directors

Please describe your personal and/or professional experience regarding the needs and concerns of people with disabilities.

Please share why you are interested in serving on the Board of Independence Associates

Resume

Click or drag a file to this area to upload.

Please provide 2 references

Name

Phone

Name

Phone