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 Year19401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 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
