Friends of Chinsegut Hill, Inc. 22495 Chinsegut Hill Road Brooksville, FL 34601 Phone: 352-799-5400 Application for Volunteer Board Positions Name:______________________________________________________________________________________________________ (Last) (First) (Middle) Address:____________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Mailing Address (if different than above):___________________________________________________________________________ ___________________________________________________________________________________________________________ Business Address:_____________________________________________________________________________________________ ___________________________________________________________________________________________________________ Occupation:__________________________________________________________________________________________________ Business Phone:______________________________________ Home Phone: __________________________________________ Email Address:________________________________________________________________________________________________ Have you ever served on a volunteer board or in a volunteer capacity before? Yes No If yes, please indicate name of board and dates of service: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Why would you like to serve on this board?_________________________________________________________________________ ___________________________________________________________________________________________________________ What special skills do you bring to this position?_____________________________________________________________________ ___________________________________________________________________________________________________________ List fields of work experience:____________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ List any licenses and/or degrees (location & year):____________________________________________________________________ ___________________________________________________________________________________________________________ Local References (please list three): 1.__________________________________________________________________________________________________________ 2.__________________________________________________________________________________________________________ 3.__________________________________________________________________________________________________________ Page 1 of 2 Page 2 of 2 Would you have any problem with the meeting dates and times for this board (the IRXUWK Thursday of every month at 3 p.m. at Chinsegut Hill)? Yes No If yes, please explain: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Additional comments: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Signed: _______________________________________________________________ Date:_________________________________