Board Member Application

Personal Information

Given Name

Surname

or Given can

Date of Birth

dd-mm-yy

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Person to Notify in Case of Emergency

Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Employment Information

Employed By

Job Title

Business Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Business Phone

Business Email

File Upload

Drag & Drop Files, Choose Files to Upload

If you have a Curriculum Vitae or Resume please attach it

Volunteer Information

Referred by: (Board Member(s)

Please list the names of any volunteer organizations you are/or have been a member of

About Section

Why are you interested in Crime Stoppers and how do you feel you can contribute?

List any special interests, skills or hobbies you have

Additional Information

Application Summary

PLEASE READ THE FOLLOWING BEFORE SIGNING

I understand that my application will be discussed by the present members of the Brant-Brantford Crime Stoppers Board of Directors. I authorize the Brantford Police Service and/or Ontario Provincial Police to obtain the information they may have concerning any convictions or criminal offenses relating to me and to divulge any such information to the Brant-Brantford Crime Stoppers board. If accepted I would be willing to take an Oath of Secrecy and maintain the confidentiality of all Crime Stoppers information. I understand that if I am accepted to the Board I will be required to attend all Board of Directors meetings and Working Committee meetings in accordance with the governing bylaws as set by Brant-Brantford Crime Stoppers. I agree to actively participate in fundraising ventures for the program if the Board accepts me.

I HAVE READ THE ABOVE AND AGREE TO ABIDE WITH THE CONDITIONS AS SET OUT THEREIN

Clear Signature

Virtual Signature - Full Name

Date