Minds Matter Chicago Board Application

First Name

Last Name

Cell number

Personal email

Mailing Address

Mailing City

Mailing State

Mailing Zip Code

Birthdate

MM/DD/YYYY

Partner's name (if applicable)

Race

Please tell us your race

Are you Hispanic or Latino/Latina/Latine?

Gender Identity

Please tell us your gender identity

Pronouns

Please tell us your pronouns

Please list any language besides English that you speak fluently

Undergraduate school

Undergrad field of study

Graduate school

Graduate degree obtained

Were you a first-generation college graduate?

Minds Matter defines you as a first-generation college graduate if your parents did not graduate from a 4-year college in the United States.

Company name

Type of business

Position/Title

Work email

Work phone

Work address

Work city

Work state

Work zip code

Assistant's name

Preferred method of communication

Does your company match?

Past work history (5 years)

Please provide a short biography (250 character count):

How did you hear about MMC?

Why are you interested in applying to be on the board of MMC?

What is your experience in dealing with the education sector, social justice issues or Equity Diversity & Inclusion?

Do you have any other experience you deem particularly compelling and relevant to MMC? Write N/A if no

List former involvement -- roles and years -- with other MM Chapters (where applicable)

Is there anything else that we should know about you that would be a conflict of interest to MMC?

Select any skills/experience:

Other skills not listed above

Please list your current and past board experiences

Company/Organization #1

Membership dates

Leadership positions held

Reason for leaving

Company/Organization #2

Membership dates

Leadership positions held

Reason for leaving

Please list two references

Name #1

Phone

Relationship

Name #2

Phone

Relationship

Digital signature

Date

MM/DD/YYYY

Contact Information