APPLICATION TO BOARD OF DIRECTORS

Transcription

1 APPLICATION DEADLINE: November 17, 2017 APPLICATION TO BOARD OF DIRECTORS NAME: DATE: ADDRESS: CITY: STATE: _ ZIP: WORK PHONE: HOME PHONE: MEMBER #: HOW LONG HAVE YOU BEEN A MEMBER OF THIS CREDIT UNION? EDUCATION POST GRADUATE: UNDER GRADUATE: SCHOOL DEGREE DATE GRADUATED SCHOOL DEGREE DATE GRADUATED HIGH SCHOOL: SCHOOL DATE GRADUATED WORK EXPERIENCE (PLEASE LIST MOST RECENT FIRST) EMPLOYER: ADDRESS: DATES EMPLOYED / FROM TO PHONE: TITLE: RESPONSIBILITIES: EMPLOYER: ADDRESS: DATES EMPLOYED / FROM TO PHONE: TITLE: RESPONSIBILITIES: Page 1 of 5

2 HAVE YOU EVER BEEN CONVINCTED OF A FELONY? YES NO HAVE YOU EVER BEEN BONDED? YES NO HAS BOND BEEN REFUSED? YES NO IF SO, WHY? PLEASE PROVIDE TWO PERSONAL OR PROFESSIONAL REFERENCES: _( ) _( ) NAME ADDRESS BUS. PHONE HOME PHONE _( ) _( ) NAME ADDRESS BUS. PHONE HOME PHONE Page 2 of 5

3 Include the following in 250 words or less: WRITE A SHORT NARRATIVE Your current title, planned contributions to the credit union if elected to serve on the board, your interests and pursuits beyond your work as well as any honors and awards. Please include a 2 x 2 colored photo (passport photo) or a digital photo to mitfcu-nominate@mit.edu

4 LETTER OF UNDERSTANDING I understand and agree that: 1. Any material misrepresentation or deliberate omission of a fact in this application may be justification for refusal to accept me as a candidate for the Board of Directors, or if elected/appointed, I could be terminated from the position. 2. It is my understanding that MIT Federal Credit Union may conduct a thorough inquiry of my entire work history and may verify all data given in my application, related papers or oral interviews to include a credit report. I hereby authorize such inquiries and the giving and receiving of any information requested by the MIT Federal Credit Union. I also release from liability any person giving or receiving such information. I understand that falsification of data so given or other derogatory information discovered as a result of this inquiry may prevent my being considered for the Board of Directors and Committees, or if elected/appointed, could terminate my position. 3. I also understand that candidates are required to review all materials pertaining to a position on the Board of Directors including Executive Officer positions. These materials outline all the requirements for the positions and will be reviewed by me prior to my being elected/appointed. 4. I agree to attend all scheduled meetings unless properly excused and to accomplish all required training as established by policy and/or directive. Failure to participate as outlined above may result in termination from the position. 5. Application must be received by the Deadline date of. I HAVE READ AND UNDERSTAND THE ABOVE: SIGNATURE OF APPLICANT DATE SIGNED Page 3 of 5

5 DISCLAIMER: The MIT Federal Credit Union is not responsible for typos, errors or miscommunication related to the Election Process. First Advantage Background Investigation Authorization/Disclosure I authorize First Advantage, a Consumer Reporting Agency, or any of its agents to procure an investigative consumer report for volunteer service purposes, which may include information about my character, background, general reputation, personal characteristics, or mode of living. I understand that I have the right to request, in writing, information pertaining to the nature and scope of the investigation and a written summary of my rights under the Fair Credit Reporting Act. I understand that before adverse action, including the denial of my service, can be taken against me in whole or in part due to a consumer report, I will be provided with a copy of the report and a written summary of my rights under the Fair Credit Reporting Act. I also understand I may have additional rights under applicable state law. I authorize all government agencies, state department of motor vehicles, corporations, companies, educational institutions, persons, law enforcement agencies, workers compensation agencies, criminal, civil and federal courts, and former employers to release information they may have about me and release them from any liability and responsibility from doing so. Any copy of this authorization shall have the same authority as the original. Signature Date Other information: Please print clearly Name (First, MI, Last) Maiden or other names used and dates used* Address information: Please print clearly Social security number Current address (number and street) Drivers license number and state Current address (Town, State, Zip) From: To: First prior address (number and street) First prior address (Town, State, Zip) From: To: Page 4 of 5

6 Second prior address (number and street) Third prior address (number and street) Second Prior address (Town, State, Zip) From: To: Third prior address (Town, State, Zip) From: To: *This information will be used for purposes of identification only. Federal law prohibits discrimination in employment on the basis of age, race, creed, religion, sex, or national origin. Many states also prohibit some or all of the above types of discrimination and discrimination based in marital status. Authorization Form I hereby authorize MIT Federal Credit Union, its subsidiaries, affiliates, employees, and agents to make inquiry of and request information from any individuals, present and former employers, schools and colleges, credit bureaus, criminal investigation bureaus, and any other entities that may possess information concerning me or that may be custodians of records relating to me, including Worker s Compensation. I also authorize the above-described sources to release all information requested, including salary data and subjective evaluations, and I hereby release those sources from any liability for doing so. I give this authorization in connection with an application relating to volunteer service. Applicant s Signature Name (please print) Current Address Dates Current Telephone No. Previous Address Dates Date of Birth: Social Security #: Page 5 of 5