Early Learning Coaliton Board Membership Application Personal InformationName* First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneFaxEmail* Emergency Contact First Last PhoneRelationshipEmploymentName of Business/Organization*Occupation/Position*Employment Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Phone*Work CellWork Email Type of Organization*Private For ProfitNon-ProfitCommunity InvolvementPlease list up to 5 civic, professional, business and/or other organizations with which you have been affiliated as a member and/or officer:1 - Name of Organization and Dates of Membership1 - Office/Position2 - Name of Organization and Dates of Membership2 - Office/Position3 - Name of Organization and Dates of Membership3 - Office/Position4 - Name of Organization and Dates of Membership4 - Office/Position5 - Name of Organization and Dates of Membership5 - Office/PositionDo you, any of your relatives, or your business entity have a substantial financial interest in the design or delivery of the School Readiness or VPK Program or other child care program?*NoYesIf Yes, Please ClarifyDo you, any of your relatives, or your business entity work for, contract with, or serve as a vendor for any of the following agencies: Early Learning Coalition, Agency for Workforce Innovation, Department of Education, Public School district, or recognized accrediting agencies for public or private schools?*NoYesIf Yes, Please ClarifyStatement of Interest: Why are you interested in applying for Board Membership?*In what way do you believe the Coalition will benefit from your participation as a Board Member?*Have you ever been convicted of a felony?*NoYesIf Yes, Please ClarifyAre you willing to be fingerprinted for background screening purposes?*YesNoCan you commit to regular attendance at Board and Committee meetings held generally held 6 times a year?*YesNoWhat is your preferred location for contact?*WorkHomePLEASE NOTE: You must provide a copy of your resume as a part of this application, Thank You.*Please upload your resume.CAPTCHA