ASD Board Application

Please complete this form

Thank you for your interest in becoming an ASD Board Member!

The application is quick and easy:

Section 1: Basic demographic information, background, upload resume (PDF, .Doc, .Docx format)
Section 2: Background check information and e-sign application

Section 1: Basic Information

First Name *

Middle Name

Last Name *

Phone *

Email *

Address*

Address Line 2 (Optional)

City *

State *

Zip *

How long have you lived at your current address? *

Employment Information

Company *

Title *

Company Address *

Work Phone *

Work Email *

Professional Experience *

Credentials and Skills

Educational Background / Certificates *

Skills / Talents *

Current and/or Past Board Affiliations *

Current Knowledge / Experience with HIV/AIDS Related Issues *

What is your interest in ASD and why? *

Strengths you could offer the ASD Board of Trustees *

Community References (Name, organization, contact information and willingness to be contacted) *

Upload Resume

Please select and upload your resume, then click on Continue to proceed to step 2.
Resume should be in PDF (peferred format), Microsoft Word .doc, or Microsoft Word .docx.

Pick Resume *

Section 2: Background Check and Signature

You're half-way done! Please complete the remaining background check information and the two signature fields below.

Note to Prospective Board Members: PWA Coalition of Dallas, Inc. conducts criminal background checks for all prospective trustees/board members. A criminal conviction or pending criminal charge may be a factor in the nomination committee’s recommendation and the Board’s decision.

The information requested below is required to conduct a criminal history background check and will not be used for any other purpose. Discrimination on the basis of age, gender, race, sexual orientation or any other protected class status is prohibited by agency policy.

A record of conviction and/or pending criminal charges is not an absolute bar to board membership. Your completion of this form is part of the application process. Applicants must fill out the form accurately and completely. Applicants who fail to complete the form will not be further considered for board membership. An applicant’s failure to accurately and completely disclose his or her criminal conviction history may be grounds for removal from further consideration for a position.

Your Most Recent Previous Address

Previous Address

Previous Address Line 2 (Optional)

Previous City

Previous State

Previous Zip

Personal Information

Date of Birth (Example: 1/25/1950) *

SSN (xxx-xx-xxxx) *

Drivers License Number *

Driver's License State *

Gender *

Any Other Names Used

Past Convictions

Have you ever been convicted of a felony, misdemeanor or ordinance violation (including receipt of a fine) other than non-moving traffic violations? Failure to disclose a conviction for any felony will be considered an intentional omission. Please make every effort to be as accurate as possible when disclosing felonies, misdemeanors or ordinance violations.

Past Convictions? *

If yes, please complete below:

Conviction 1: Nature of the Offense / Details

Conviction 1: Date of Conviction (Month/Day/Year)

Conviction 1: Name and Location of the Court

Conviction 2: Nature of the Offense / Details

Conviction 2: Date of Conviction (Month/Day/Year)

Conviction 2: Name and Location of the Court

Pending Charges

Do you have any charges pending against you? *

If yes, please complete below:

Please indicate the nature of the pending charges

Name and Location of the Court or Jurisdiction

Pending Charges Additional Information

Electronic Signature

By signing below:

I certify that my answers are true and complete to the best of my knowledge. As a candidate for the Board of Trustees of ASD, I acknowledge that I have received, read and understand the duties and responsibilities as outlined in the Job Description for Member of the Board of Trustees. Further I agree to adhere to the duties and responsibilities as outlined.
I agree that PWA Coalition of Dallas, Inc. may conduct a criminal history background check. To the best of my knowledge, the information provided on this form is true and complete. I understand that falsification or omission of information constitutes grounds for rejection or removal.