First Name (required)

Last Name (required)

Your Email Address (required)

Your Phone Number (required)

Street Address (required)

City (required)

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Zip (required)

What is your current occupation? (required)

What skills or talents do you possess that may be an asset to CCHS? (required)

Why are you interested in serving on the board? (required)

Have you ever served on a board? (required)
—Please choose an option—YesNo

If yes, where?

If yes, how long?

What community-based groups or activities are you or have you been involved with? (required)

The board meets the fourth Tuesday of each month and sub-committees meet monthly and/or as needed for approximately one hour. These meetings are usually in the evenings after work. Are you willing to commit to this amount of time and effort on a regular basis? (required)
—Please choose an option—YesNo

Are there issues that would limit your participation? (required)
—Please choose an option—YesNo

We appreciate your interest in serving on the board of the Chautauqua County Humane Society (CCHS.). Serving on a non-profit board is rewarding and involves time and commitment. In order to be considered, please complete this statement of interest form. The Nominating Committee may request an interview with you after reviewing your form.

In signing this statement, I certify that all of the information provided is accurate. If any misrepresentation, omission or falsification is found it will constitute grounds for non-acceptance to the board or dismissal from the board. I understand and agree that, if appointed by the board, I will abide by the policies, rules and stipulations, which are subject to change. I further understand that, if appointed, the terms of the appointment will be those presented to me when approved/appointed. The CCHS Nominating Commitee Chair will respond to your submission.

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