PhilMO Leadership Interest Form

First Name

Last Name

Organization

Title

Email

LinkedIn Profile URL

Geographic Location

Gender

Female Male Non-Binary Other Prefer Not to State

Birth Year/Age

Before 1946 1946-1964 1965-1980 1981-1996 1997-2012 Prefer Not to State

Race/Ethnicity

Asian / Asian American Black / African American Hispanic / Latina / Latino / Latinx Middle Eastern / North African Multi-Racial / Multi-Ethnic Native American / American Indian / Alaska Native / Indigenous Native Hawaiian Other Unknown or Prefer Not to State White / Caucasian / European

Disability

Person with a disability Person without a disability Unknown or prefer not to state Other

Sexual Orientation

Heterosexual / Straight LGBTQ+ Community Unknown or Prefer Not to State Other

Are you interested in serving on the Board of Directors?

Yes

No

What committee(s) interest you? (mark all that apply)

Audit

Engagement

Finance

Governance

Programs & Services

Please mark the competencies you have and are willing/able to offer PhilMO (mark all that apply):

Communications

Finance/Investment

Fund Development

Justice/DEI

Legal/Regulatory

Nonprofit Governance

Programming

Strategy

Systems Change/Advocacy

Other

What interests you about PhilMO service at this time? What else would you like to share?