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Do you have a current PA Driver's License?
EDUCATION
Highest Grade Level Completed
Are you presently enrolled as a student
EMPLOYMENT HISTORY
Are you presently employed
Are you retired


VOLUNTEER EXPERIENCE AND TRAINING

(If you have volunteered at another organization)




REFERENCES


BACKGROUND INFORMATION

(Please answer the questions below as completely as possible.)



Do you have any physcial disabilities that may affect or limit your work
Are you on any medication(s) and/or under medical supervision
Have you ever been convicted of a felony
GENERAL QUESTIONS
BOARD MEMBER OPPORTUNITY

(If you are interested in the opportunity of Board Member for Agency of Governance, please answer the following questions.)

CERTIFICATION OF APPLICANT

By submitting this form, you certify that your answers on this application are true and complete to the best of your knowledge. You also grant your permission and consent for us to contact the necessary resources and references to verify your responses on this application.