VOLUNTARY ACTION CENTER
829 Jefferson Avenue – Scranton, PA 18510
Phone: (570) 347-5616 · Fax: (570) 341-5816
Email: [email protected]
www.vacnepa.org
BOARD BANK – AGENCY REQUEST –
for use by nonprofits looking for Board Members
AGENCY NAME: __________________________________________________________
ADDRESS: _______________________________________________________________
CITY: ________________________________ STATE: _______________ ZIP: ________
Executive Director: _______________________________________________________
PHONE: ____________________________ EMAIL: ______________________________
CONTACT PERSON if other than ED: _________________________________________
PHONE: ____________________________ EMAIL: ______________________________
CURRENT BOARD MEMBERS/TITLES
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
CURRENT NUMBER OF OPEN BOARD POSITIONS: ___________________________________________
ANTICIPATED VACANCIES: _______________________________________________________________
BOARD/ADVISORY COUNCIL MEETINGS ARE USUALLY HELD:
LOCATION:
________________________________________________________________________________________
________________________________________________________________________________________
FREQUENCY: ____________________________ DAY: ________________________ TIME:
________
VOLUNTEERS WITH EXPERTISE IN THE FOLLOWING AREAS SHOULD BE CONSIDERED FOR OUR
AGENCY:
__________ ADMINISTRATIVE
__________ FINANCE/ACCOUNTING
__________ FUNDRAISING
__________ LAW
__________ OTHER (Please List)
__________ MARKETING
__________ PERSONNEL MANAGEMENT
__________ PUBLIC RELATIONS
__________ SPECIAL EVENTS
VOLUNTEERS INTERESTED IN THE FOLLOWING AREAS SHOULD BE CONSIDERED FOR OUR AGENCY:
_______ ANIMALS
_______ CRIMINAL JUSTICE
_______ EDUCATION
_______ ENVIRONMENT
_______ FINE ARTS
_______ GOVERNMENT
_______ PHYSICAL DISABILITIES
_______ HEALTH
_______ MENTAL HEALTH
_______ RECREATION/SPORTS
_______ SENIOR CITIZENS
_______ SOCIAL SERVICES
_______ SUBSTANCE ABUSE
_______ URBAN CONCERNS
_______ VOLUNTEERISM
_______ CHILDREN/YOUTH
_______ OTHER (Please List)
_________________________
_________________________
THE BOARD BANK IS DESIGNED TO ESTABLISH A REFERRAL SERVICE TO
AGENCIES/ORGANIZATIONS, PROVIDING A LISTING OF POTENTIAL BOARD MEMBERS.
IT IS THE RESPONSIBLILITY OF EACH AGENCY/ORGANIZATION TO SCREEN AND
EVALUATE EACH APPLICANT WHO IS REFERRED.
______________________________________
AGENCY REPRESENTATIVE
_______________________________
TITLE
______________________________________
DATE
ENCLOSE ANY BROCHURES, FACT SHEETS, NEWSLETTERS, ETC., WHICH DESCRIBE
YOUR ORGANIZATION’S MISSION.
Voluntary Action Center
829 Jefferson Avenue, Scranton, PA 18510
Phone (570) 347-5616 *FAX (570) 341-5816
[email protected]
BOARD BANK APPLICATION –
for use by individuals wanting to serve
NAME: ________________________________________________ AGE (Optional): _______________
ADDRESS: ___________________________________________________________________________
CITY: ______________________________________ STATE: _________________ ZIP: ____________
PHONE: (Work) _____________________________ (Home) ___________________________________
EMAIL: _______________________________________________________________________________
CURRENT EMPLOYER: _________________________________________________________________
CURRENT POSITION: ___________________________________________________________________
AREA/AREAS OF PREFERRED INTEREST (Please review the list thoroughly and indicate the areas in which you
are most interested):
_____
_____
_____
_____
_____
_____
_____
ANIMALS
CRIMINAL JUSTICE
EDUCATION
ENVIRONMENT
FINE ARTS
GOVERNMENT
PHYSICAL DISABILITIES
_____
_____
_____
_____
_____
_____
HEALTH
MENTAL HEALTH
RECREATION/SPORTS
SENIOR CITIZENS
SOCIAL SERVICE
SUBSTANCE ABUSE
_____ URBAN CONCERNS
_____ VOLUNTEERISM
_____ CHILDREN/YOUTH
_____ OTHER (Please List)
________________________
________________________
TIMES I AM AVAILABLE FOR MEETINGS:
_____ MORNINGS
_____ AFTERNOONS
_____ EVENINGS
REASONS FOR MY INTEREST IN BOARD ACTIVITY:
COMMUNITY SERVICE EXPERIENCE (i.e., Boards, Committees, Civic Clubs)
(Previous):
(Current):
OTHER VOLUNTEER WORK I HAVE DONE:
LEADERSHIP/BOARD TRAINING I HAVE RECEIVED:
AREAS IN WHICH I HAVE EXPERTISE:
_____ ADMINISTRATIVE
_____ FINANCE/ACCOUNTING
_____ FUNDRAISING
_____ OTHER (Please List)
_____
_____
_____
_____
LAW
MARKETING
PERSONAL MANAGEMENT
PUBLIC RELATIONS
IF YOU HAVE AN INTEREST IN A SPECIFIC AGENCY, PLEASE NOTE IT HERE:
WHAT DO YOU FEEL YOU CAN OFFER TO AN AGENCY/ORGANIZATION?
ADDITIONAL COMMENTS:
HOW DID YOU LEARN ABOUT THE BOARD BANK?
_____ AGENCY
_____ FRIEND/FAMILY
_____ LEADERSHIP LACKAWANNA
_____ WEBSITE
_____
_____
_____
_____
BROCHURE
MEDIA
VOLUNTEER FAIR
OTHER (Please Specify)
CONSENT
I authorize the VOLUNTARY ACTION CENTER to share the information I have submitted herein with interested
agencies/organizations in order to facilitate the assessment and referral process for possible Board Membership.
SIGNATURE: ______________________________
DATE: __________________________________
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