Prospective Board Member Information Form "*" indicates required fields Name* First Last Current Organization / Company & Title*(if relevant)Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Cell Phone Number*Which best describes you?*Select all that apply Asian American Indian or Alaskan Native Black or African American White Hispanic, Latinx, or Spanish origin Middle Eastern or North African Native Hawaiian or other Pacific Islander Some other race, ethnicity, or origin Prefer not to answer Special Skills*Select all that apply Administration / Management Advocacy / Public Policy Corporate Governance Education Entrepreneurship Finance / Financial Management / Banking Fundraising Government Healthcare / Medical Hospitality Human Resources Insurance Leadership Coaching Legal Marketing / PR / Communications Nonprofit Management Operations Program Development Real Estate Digital Media Strategic Planning Technology Other Professional Background*Select all that apply For profit business Nonprofit organization Government Other If "Other" chosen above for Special Skills and/or Professional Background, please describe below:Why does the BluePath mission resonate with you?*Are you currently serving on any other Boards or have you served on Boards in the past? If so, which ones and when?*If appointed to the Board, what level of financial contribution are you prepared to annually contribute or secure for BluePath?*Anything else you’d like to share?Upload resume or bio, with at least two references.* Drop files here or Select files Max. file size: 50 MB. Background Check Consent*I hereby authorize BluePath Service Dogs, Inc. and its designated agents and third party company representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for the purposes of a business and/or client relationship, including, but not limited to, employment, volunteer opportunities, or client/dog recipients. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to, the following areas: criminal national database search (sex offenses, terrorist watchlist, FDA, GSA, OFAC, OIG); social security number; federal criminal national database; driving record; alias for all. I further authorize any individual, company, firm, corporation, organization, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to BluePath Service Dogs, Inc, contracted third party agency, and any/all agents or representatives. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, organization, or public agency may have, to include information or data received from all sources. I understand that I have the right to deny consent to the review of my background, and agree that BluePath Service Dogs, Inc. reserves the right to deny my application or terminate a partnership based solely on those grounds. I further agree, should I authorize BluePath Service Dogs, Inc. to review my background, the information provided from the data pertaining to me will be carefully reviewed, allowing BluePath Service Dogs, Inc. to take action of an appropriate nature, as they see fit, based on the findings from the consumer report, or investigative consumer report. I understand that while BluePath Service Dogs, Inc. does not automatically terminate or disqualify business relationships, including employment, volunteering, or client /recipient, for past criminal activity, certain offenses may eliminate me from such partnership especially if the offense is related to the responsibilities of the role (e.g., violent crimes, sexual offenses, recent major driving violations). I further understand that factors, such as, the nature of the offense and its relation to the role, the time that has passed since the offense and evidence of rehabilitation will be considered. I further authorize BluePath Service Dogs, Inc. to decide the appropriate course of action should a consumer report or investigative consumer report come back with unfavorable information. I understand that appropriate action could include, but is not limited to, termination of any/all relationships with the organization and its representatives, a new/different role within the organization, revoking driving privileges from organization vehicles or its professional property (including, but not limited to, service dogs and organization owned equipment), or an ineligibility for some or all future opportunities to partner with the organization, its affiliates, representatives, or individuals with a past partnership to the organization. According to the fair credit reporting act (FCRA), I am entitled to know if the considerations for which I am applying are denied because of information obtained from a consumer-reporting agency. If so, I will be notified and be given the name of the agency providing the report. I will also be provided with the report itself; any actions taken because of the report, in writing; and a copy of the FCRA summary of rights for my review. I will be given an opportunity to formally, in writing, dispute any actions taken against me within 7 business days of notice for BluePath Service Dogs, Inc. review and reconsideration, with an understanding that there is no guarantee the organization will choose a new appropriate action. By signing this document, I am providing BluePath Service Dogs, Inc. consent for an initial background check as well as any subsequent background checks deemed necessary, which can occur randomly and without warning, regardless of my current status (e.g. active or inactive) with the organization. I provide consent for a background checkName* First Middle Last Signature*Date* MM slash DD slash YYYY Email* Phone*CAPTCHA
