Board Member Application

1933 Main Street, Torrington WY 82240 - 307-532-0269 - Serving Carbon, Crook, Goshen, Niobrara, Washakie, & Weston Counties as of October 1st, 2020.

Goshen HELP is a 501(C)3 Tripartite Board. Our board is regulated by Section 9910(b)1 and (2) of the Federal CSBG act. Sections 676B of the Community Sevices Block Grant Reauthorization Act of 1998 requires, that as a condition of designation, private nonprofit entities and public organizationas administer their CSBG program through tripartite boards that "fully participate in the development, planning, implementation, and evaluation of the program to serve low-income communitites."

A tripartite board must have 1/3 of its board membership be democratically seleected representatives of low-income individuals and families who reside in the geographic area being served by the agency, 1/3 of its board membership must be public office elected officials, holding office at the time of their selection, or a representative chosen by the elected official, and 1/3 of its board membership must represent major groups and interests in the community which includes business, industry, labor, religious, law enforcement, or education.

Date*

Date

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Employer (If employed)

Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer's Phone Number

Area CodePhone Number

Supervisor's Name

First NameLast Name

Occupation or Role

Source of income if not employed

Do you forsee any conflict of information between serving on our board and working for your employer? If yes, please explain.

List any previous experience you may have with serving on boards or committees. Please include name of the organization, your role and responsibility, and dates.

Please list any training you may have received that you believe would benefit Goshen HELP.

Please include 2 personal references (not related to you) who can speak to your abilities and experiences. Please include contact information.

Which type of board seat would you best qualify for?

Representing customer base (low-income)Public OfficialGeneral Public

Goshen HELP Board Member Application