Board Application

Application for CareerSource NCFL Membership

First Name

Last Name

Organization/Employer Name

Occupation/Title

Prior Occupation (if retired)

Organization Address

Organization is located in

Number of Employees in Company

Phone Number

Alternate Number

Fax Number

Email Address

Preferred contact email

Contact Phone

III.a Gender (Optional)

III.b Race (Optional)

III.c Citizenship (Optional)

III.d Veteran / Active Military (Optional)

Veteran

Active Military

III.d Branch (if Yes)

III.e Educational Degrees / Training (Optional)

IV. Interest in becoming a member

Special experience/training/qualifications

VI. Other current/previous Board membership

VII. Personal information (optional)

VIII. Conflicts of Interest

Send annual financial disclosure form to

Signature (typed)

Signature Date

County of Residence

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