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Board Fellowship Organization Application 

 General Information


Organization Name:   
Street Address:   
City, State, Zip:   
Organization Phone:    
Organization Email:  
 Executive Director:   
 Name of Board Chair:   
 Date Org. Established:   

Organization Mentors 

The most important relationship in our program is between the student and Board Mentor. A staff member is important to stay connected to the operations, but the primary relationship is with the board mentor.


Name of Board Member/Mentor:    
(Professional) Employer Company/Title:   
Board Mentor Phone:    
Board Mentor Email:   
Name and Title of Executive Staff Contact:   
Staff Contact Phone:   
Staff Contact Email:    


 Mission and Services

Please check the category that best represents your organization’s mission:  


Organization Mission Statement: 
Please describe the major programs or services within your organization: 


Board Operations 


Number of Board Members:  

Please provide details about your board meetings:

Number per year:  
Average Meeting Length:
Day of Week/Month:
Typical Location(s):  


Please indicate the skills and expertise you wish to add to your board (check all that apply):

(This information is useful in matching your Board Fellow.)



Please estimate the average number of hours an individual board member contributes each month (including outside of meetings):


How many Board Fellows would you like placed on your board?


Financial Information

 Annual Budget:  
 Number of FTEs:  


Top three major funders (need not disclose amounts):







Board Agreement

 Please provide the following documents:

  • List of current board of directors, including full name, affiliation, title/position, beginning and ending dates of board term
  • Copy of board minutes showing a resolution to participate in the Board Fellowship Program and oversee and support a board fellow (see Board Agreement section)
  • Any additional material you think would be helpful (e.g., annual report, newsletter, financial audit, brochure)


Printed Name:   
Date:   [None] Select a Date Delete the Date



Parvez Ahmed, Director