Personal Information First Name Last Name Formal Title Dr. Mr. Mrs. Miss Ms. Personal Mailing Address City/State/Zip Code Prefered Email Address for Board Correspondence Preferred Phone Number Is this number a cell or work number? Cell Work Spouse/Partner Name Date of Birth Date of Birth: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of Birth: Day Day12345678910111213141516171819202122232425262728293031 Date of Birth: Year Year194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Are You a Veteran? Yes No If Yes, which branch of the military Work Information Title Company/Organization Work Address City/State/Zip Code Email (If Different) Work Phone Administrative Assistant Information (if applicable) First & Last Name Email Address Work Phone Additional Information Are you active on Social Media? Yes No Check all that apply LinkedIn Facebook Instagram X (Formerly Twitter) Please provide Social Media handles: Is someone assigned to monitor your Social Media, if so, please list there name and contact info. Do you serve on any Non-Profit Boards? If so, please list: As you know, United Way holds several events throughout the year and is always looking for prize packages to offer. If you are a member of a country club, have an affiliation with local entertainment/sports venues, hold season tickets or have any additional memberships, please list. Please provide a recent headshot Upload Upload requirementsOne file only.200 MB limit.Allowed types: gif, jpg, jpeg, png. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank
