Board Bank Application Personal InformationName First Last Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Personal Email Cell PhoneIs your home address your preferred address? Yes No Is your personal email your preferred email? Yes No How many years have you been a Lubbock resident?Registered voter? Yes No Employment InformationOccupationBusiness NameBusiness Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Work Email Business PhoneFaxIs your business address your preferred address? Yes No Is your business email your preferred email? Yes No Demographic InformationEthnic Background Anglo Hispanic African American Other Gender Male Femal Age 18-29 30-39 40-49 50-59 60+ Personal ExperiencePlease list any experience (including board service or involvement in other civic or community organization), education or interest that would qualify you to serve on a nonprofit board or committee:Conflict of InterestDo you know of any reason you might have a conflict of interest as a result of your service on a nonprofit board or committee? Yes No If yes, please explain:Personal and Professional References (please give names and phone numbers)Name First Last PhoneName First Last PhoneName First Last PhoneAreas of InterestPlease select your areas of interest: Aging/Elderly AIDS Alcohol/Drug/Substance Abuse Animals Arts-Visual Business/Financial Training Child Abuse Child Care Civic Engagement Crime Prevention Dance Domestic Violence Education Emergency/Disaster Assistance Employment/Job Training Environment Family Service Health Homelessness Hospice/Terminally Ill Hunger Illiteracy Legal Assistance Mental Health Mental Retardation Museum Music/Symphony Physically Handicapped Sexual Abuse Sports/ Recreation Suicide/ Crisis Intervention Theater/ Dramatic Arts Volunteerism Women's Issues Youth/Teen Other If other, please describeOrganizations of Interest1.2.3.SignatureSignatureDate PhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.