Board of Directors Application

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Background Information

License and License Number

Please provide for us your license and license number.

Professional History

Please attach with this application an outline of your educational and professional history, including volunteer experience. In lieu of this, you may provide your CV or the URL of your LinkedIn profile. If you also have any other professional web presence (e.g. professional webpage, Psychotherapy Today listing), please list that information here:

File Attachment

Upload an outline of your educational and professional history, including volunteer experience here.

Drop files here or

Accepted file types: doc, docx, pdf, pages, Max. file size: 32 MB, Max. files: 2.

Introduction

What interests you or prompts you to join the NPI Board of Directors?

Interests

Tell us in which areas you are interested in volunteering:

Choose all that apply.

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports. What do you hope to contribute?

Emergency Contact

Who should we contact in case of an emergency?

Name

First Last

Relationship

Mobile Phone

Work Phone

Email

Agreement

Agreement Confirmation

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

Yes

Name

Please type your name as confirmation of the above.

Policy

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Thank you for completing this application form and for your interest in volunteering with us.

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Name

This field is for validation purposes and should be left unchanged.

Background Information

Introduction

Interests

Emergency Contact

Agreement

Policy

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