Board Member Information Form
Personal Information
Date Completed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
Last Name
First Name
Formal Title (e.g., Dr/Mr/Miss/Mrs/Mx)
Pronouns
Preferred Email for Board Correspondence
example@example.com
Personal Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Demographic Information
This section is OPTIONAL. Please keep in mind that many funders request information regarding our Board Members' personal information to assess our Board diversity and the representation of communities most impacted by HIV.
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender Identity
Ethnicity
Race
Sexual Orientation
HIV Status
Business/Work Information
Title/Profession
Company/Organization
Email (if different)
example@example.com
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone
Format: (000) 000-0000.
Extension
Administrative Assistant Contact Information.(if applicable)
Bragging Links: Please insert links to your Linked In or any resources you want to share that highlight your work
Headshot (Upload Here)
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Upload Bio (or insert LinkedIn link to your bio above)
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