150 Benefit Street,
Providence, Rhode Island
Membership and/or Board of Directors Application
Name
_____________________________________________________________________________ First Middle Last
Residence Address: ________________________________________________________________
Phone __________________________ E-mail________________________________________
Interested in joining as a member _______ Annual Dues: $10.00
Interested in serving as director _______ Only members are eligible to serve as directors
If you are interested in serving as a director, please complete portions 1- 4. If not, skip to the end.
1. Please briefly describe your academic and professional background:
2. Please list any prior experience as a member or director of other non-profit organizations:
3. Please describe the contribution you feel you can make to further the Subcommittee’s mission:
4. Please share or attach any other information you feel important:
Signature of applicant: ______________________________ Date _________________________
Thank you very much for applying