E-mail Address:

Address Home: Work:

Phone: Home ()-     Work: ()-

FAX: ()-     TDD: Yes No

Occupation:     Title:

Please describe your experience with and knowledge of Independent Living:

Please describe your experience with disability:

Why are you interested in serving on the Board of Directors? Please describe any special expertise or skills that would be of benefit to PIRS.

Please describe your experience with fundraising activities, for example, special events, grant-writing, corporate or foundation requests, etc.

Directors generally work 6 - 8 hours per month in addition to fundraising activities. This include. serving on at least one committee such as Finance, Personnel, Program, Fundraising, etc.