Board Application

First Name *

Last Name *

Email (Personal) *

Address (Personal) *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone Number (Personal) *

Email (Professional) *

Professional Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone Number (Professional) *

Highest Degree Earned as of Present: *

Bachelor's
Master's
Doctoral

Please share the area of concentration and degree earned for each of your degrees: *

Please list all of the professional credentials and certifications you hold (Example: PhD, CRC, CVE): *

Please share your current primary work setting: *

If you selected "other" to the question above, describe your current work setting:

Gender *

(you may respond "prefer not to answer")

Age *

(you may respond "prefer not to answer")

Race/Ethnicity *

If you selected other, please share your self-identified race/ethnicity:

Do you wish to disclose that you have a disability? *

Yes
No
Prefer Not to Answer

If yes, please specify:

Will you require CRCC to provide any accommodations to fully participate in Board meetings/activities? *

Yes
No

If yes, please specify:

How did you learn about the open Board of Director position? *

Email from CRCC
CRCC Website
Referred by Colleague/Friend/Acquaintance
Other

If other, please specify:

Please select the areas of expertise in which you possess skills, knowledge, and proficiency to support the work of the CRCC Board of Directors *

1) Please describe past engagement with CRCC (committee work, taskforce, etc.) If not applicable enter N/A. *

2) Reflecting on the ratings for Knowledge provided above, describe the strengths of each of those attributes and how would you bring those to the CRCC Board of Directors: *

3) Summarize your current or prior employment experience or practice responsibilities related to rehabilitation counseling. If not applicable enter N/A. *

4) If you are not in the rehabilitation counseling profession, please describe your work history: *

5) List membership(s) and/or any leadership experience in relevant national or local professional organizations or list other applicable volunteer service experience: *

6) If you currently serve on any boards or committees, please list the organization, your role and when your term expires: *

7) Why do you wish to serve on the CRCC Board of Directors? *

8) If you are a Certified Rehabilitation Counselor, what do you see as the top 5 critical issues facing the rehabilitation counseling field and to CRCC? Also, please summarize what you think CRCC can be doing to help resolve some of the critical issues. *

9) How would your service as a Director support CRCC’s mission and vision? *

10) What is your definition of a leader? *

11) Now or in the future, would you consider taking on a leadership role (e.g., President, Vice President or Treasurer position)? *

12) Is there anything of an ethical or legal nature in your background that would preclude you from discharging your duties as a member of the CRCC Board of Directors? *

Resume/Vitae (2 Pages Maximum) - PDF Only *

Drop your file here or click here to upload You can upload up to 1 files.

Letter of Recommendation #1 - PDF Only *

Drop your file here or click here to upload You can upload up to 1 files.

Letter of Recommendation #2 - PDF Only *

Drop your file here or click here to upload You can upload up to 1 files.

I have provided a copy of my current two-page (maximum) vitae/resume. *

Yes

I have provided two letters of recommendation from professional references that speak to my competencies as a Board of Director, including characteristics such as strategic thinking; leadership; business understanding; responsible stewardship; diversity of thought, experience, and representation; and impact and influence within the rehabilitation counseling community. *

Yes

I have read the materials that were provided with regard to the Director Position Description and Code of Conduct. If elected to serve, I will fulfill the duties and responsibilities of a Board of Director with integrity, collegiality, and due care. Furthermore, barring any unforeseen circumstances, I am able to commit to participating in two in-person meetings per year requiring a commitment of three days each, including travel time, at the expense of CRCC. In addition, I am able to commit to participating on video conferences and communicating via email in order to conduct business between in-person meetings. *

Yes

I understand the Board of Director position is a three (3) year commitment. *

Yes

I understand that, if elected, I will be required to also serve on a CRCC committee. *

Yes

Signature (Please input your first and last name) *

Date (Please Type)

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