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Board Member Request Form
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
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3.
Title
(Required.)
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4.
Email Address
(Required.)
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5.
Work Phone Number
(Required.)
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6.
Organization's Name
(Required.)
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7.
Organization's Mailing Address
(Required.)
Address 1 (Street Name and Number)
Address 2 (Suite Number)
City
State Abbreviation
Zip Code
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8.
Organization's Mission Statement
(Required.)
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9.
Organization's Website
(Required.)
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10.
Tax ID Number
(Required.)
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11.
Social media links
(Required.)
12.
Describe the duties and responsibilities of the potential board member
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?
(Required.)
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15.
What is the potential board member's time commitment?
(Required.)
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16.
How long is the board term?
(Required.)
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17.
When does the board term start?
(Required.)
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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)
(Required.)
Choose File
No file chosen
19.
Please upload board member recruitment materials. (This could include a recruitment letter, bylaws, board directory, marketing collateral, or other documents)
Choose File
No file chosen
20.
Please upload board member recruitment materials. (This could include a recruitment letter, bylaws, board directory, marketing collateral, or other documents)
Choose File
No file chosen
