Step 1 of 3 0% Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* Occupation (or former occupation if retired):* Business name (if applicable): How many years have you been a member of Cloverland Electric Cooperative?* Best time of the day and time to reach you by phone* How did you learn about Cloverland Cares?* Memberships in civic/community organizations*(Click the + button to add a new row)Organization NameLocationOffice HeldDates Brief biography of relevant experience*Other nonprofit or board experience*Other affiliations (individuals, corporations, foundations)*What are your primary reasons for considering to serve on board of directors for Cloverland Cares?* Please write a brief statement of your understanding of the mission of Cloverland Cares*Please list any potential conflicts of interest you may have with serving on the Cloverland Cares Board of Directors*Additional comments (or attach any additional relevant information)*Applicant Consent* I hereby verify the above information to be true and complete. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)*