Board Member Request Form

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* 1. First Name

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* 2. Last Name

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* 3. Title

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* 4. Email Address

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* 5. Work Phone Number

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* 6. Organization's Name

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* 7. Organization's Mailing Address

Address 1 (Street Name and Number)

Address 2 (Suite Number)

City

State Abbreviation

Zip Code

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* 8. Organization's Mission Statement

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* 9. Organization's Website

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* 10. Tax ID Number

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* 11. Social media links

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* 12. Describe the duties and responsibilities of the potential board member

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* 13. Has a Arkansas Blue Cross Blue Shield employee served on this board previously?

Yes

No

If so, who was the board member?

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* 14. What is the potential board member's financial commitment?

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* 15. What is the potential board member's time commitment?

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* 16. How long is the board term?

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* 17. When does the board term start?

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* 18. Please upload board member recruitment materials. (This could include a recruitment letter, bylaws, board directory, marketing collateral, or other documents)

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* 19. Please upload board member recruitment materials. (This could include a recruitment letter, bylaws, board directory, marketing collateral, or other documents)

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* 20. Please upload board member recruitment materials. (This could include a recruitment letter, bylaws, board directory, marketing collateral, or other documents)