Disability Rights Florida Application for Appointment to the Board of Directors

Applicant Name and Contact Information

First Name

Last Name

Home Phone

Work Phone

Mobile Phone/Text

Address Line 1

Address Line 2

City

State

Postal Code

Employer Information

Employer

Type of Organization

Title or Position

How Long Employed Here?

Business Phone

Business Email

Business Address Line 1

Business Address Line 2

City

State

Postal Code

Business/Professional Affiliations

Affiliation

Name of Group

Positions Held or Assignments

Dates

Community Involvement: List up to five community activities in which you have played an active role

Community Activity

Organization

Assignment/Postion

Responsibilities

Dates

Narrative Questions

Disability Rights Florida’s Board values diversity and its members reflect the demographics of the state of Florida as well as have knowledge and experience with disabilities. What qualities would you bring to maintain diversity on the Board: for example, race, ethnicity, disability experience, family member, languages, etc.

DRF has a conflict-of-interest policy for Board members. The policy defines “conflict” as:

“A conflict of interest may exist when the interests or activities of any Director, Advisory Council member, or staff member may be seen as competing with the interests or activities of the Corporation, or when a Director, Advisory Council member, or staff member derives a financial or other material gain as a result of a direct or indirect relationship.”

Have you, in a personal or professional capacity, worked with or provided services to an entity or persons that might, in your good faith judgement, present or appear to present a conflict with the mission or priorities of Disability Rights Florida? If so, please explain.

If your answer to the previous question is “yes,” do you have a proposal to mitigate the potential conflict?

What skills and experience would you bring to the Board’s governance, fiduciary and legal oversight responsibilities?

Describe your volunteer experience in the last twelve months.

If you have not had the time or interest to become actively involved in community or volunteer work, what conditions have changed that now enable you to serve on this Board of Directors?

List three major challenges facing individuals with disabilities today.

Give your recommendations for addressing one of the above challenges.

After learning the mission statement of Disability Rights Florida, what do you hope to achieve from your participation in Disability Rights Florida?

References: List two references who would support your application to serve on the Board of Directors

Reference 1

Name

Phone

Reference 2

Name

Phone

Please upload your resume or C.V.

Participant Commitment:

I understand the requirements as outlined in the Disability Rights Florida Bylaws and I agree to abide by them. If I am selected, I will devote the time and resources necessary to complete orientation and become an active member of the Board of Directors. I understand the above commitments and agree to be bound by them by submitting this application.

Contact Information