Board Member Application

Please complete only one application:

• Online: Fill out and submit the form below.

• Printable: Download the file at the bottom of this page if you prefer a paper copy.

Candidate Information

Candidate(Required)

First Name Last Name

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

What is your field of employment?(Required)

Education(Required)

Relevant experience and/or employment within bleeding disorders community

Relevant civic/business experience and/or employment

Why are you interested in serving on the MHA Board of Directors?(Required)

Areas of expertise/contributions you can make to MHA as a Board Director:(Required)

Other current volunteer commitments:

List additional affiliations or organizations (e.g. memberships, professional, civic)

Please mark any of the following skills or experience you possess.(Required)

Finance/Accounting

Grant Writing

Fundraising

Event Planning

Public Relations/Communication

Management/Administration

Nonprofit Experience

Teaching/Curriculum Development

Network/Contacts

Other

If Other, please specify(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

MHA Board Application

If submitting the printable version, mail the completed application to:

Midwest Hemophilia Association
202 E. Elm St., Suite H
Ozark, MO 65721