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PBHAC Board of Directors Application
Please complete the following form and the indicated steps to apply to serve as a member of the Coalition's Board of Directors.
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The deadline to apply for a position on PBHAC's Board of Directors ended on Friday, January 23. Feel free to complete the following application and you will be considered for the 2016 Board openings. Thank you!
You have two options to complete an application to serve on our Board of Directors. You may complete the form online by answering the questions below. If you prefer to download a Word application, please download the application from the following link:
http://www.olderpa.org/Resources/Documents/Board/Board%20Application%20O97.doc
First Name
*
Your answer
Last Name
*
Your answer
Home Address
Please enter your complete home address, including Street, City, State and Zip Code
Your answer
County of Residence
Your answer
Home Phone
Your answer
Personal Email Address
Your answer
Company (If applicable)
If not working or retired, please indicate this
Your answer
Title (If applicable)
Your answer
Work Address
Please include entire work mailing address, including street, city, state and zipcode
Your answer
Primary County of Work
Your answer
Work Phone
Your answer
Work Fax
Your answer
Work Email
Your answer
Work Cell
Your answer
I prefer to be contacted at the following email address:
*
Personal Email
Work Email
I prefer to be contacted at the following phone number:
*
Home Phone
Work Phone
Personal Cell
Work Cell
Required
Please check all in which you have expertise or experience:
Please check all that apply
Event Planning
Advertising & Creative
Education/Training
Public Relations
Legal
Finance
Fundraising
Technology
Policy
Writing, Journalism
Advocacy
Mental Health System
Substance Abuse System
Aging System
Other Social Service System
Other:
Our Goal is to include older adults and consumers as important members of the Board of Directors. If you are willing, please indicate this below:
I am an older adult
I am a past or present consumer of behavioral health services
Are you now serving as a board member of another non-profit organization? If yes, please specify:
Your answer
Why are you interested in serving on the Board of Directors?
*
Your answer
What areas of expertise or contributions do you feel you can contribute to PBHAC?
Your answer
How do you think the PBHAC Board mightbest take advantage of your expertise?
Your answer
Additional comments or questions for the PBHAC Board:
Your answer
Please send your resume or bio to the following: Email -
info@olderpa.org
; Fax - 717-370-6016; USPS - PBHAC 525 South 29th Street. Harrisburg, PA 17104
*
I will send my resume or bio
I do not have a resume or bio
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