QIC Board of Directors Application |
| Date |
| Name |
| Address |
Phone: (W): ___________________________ (H): ____________________________ (Other Phone): ________________________ (Fax): ___________________________ |
Email: |
Please describe your experience / background related to persons with disabilities (i.e. parent or family member of a person with a disability, professional, educator, person with a disability, etc.)
|
Please describe the reasons for your interest in becoming a Board member and what you hope to contribute to the Board.
|
| Thank you for
your interest in serving as a Board member for QIC. Please feel free
to attach additional sheets and/or a resume as appropriate. 02/04 |