Board of Directors Candidate Application

Belmont Academy Charter School

1476 SW Walter Ave. Lake City, Fl 32024

(386) 487-0487

Board of Directors Candidate Application

Date*

Answer Required

Last Name*

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First Name*

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Middle Initial

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Familiar Name

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Residence

Address*

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Years living in Columbia County*

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Phone*

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Email*

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Employer

Name*

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Your title*

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Year/Months in current business:*

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Address*

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Work Phone*

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Work Email

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Type of business or organization*

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Primary service(s) and area/population served*

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Preferred method of contact: *

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Work

Residence

Please list boards and committees that you serve on, or have served on

(business, civic, community, fraternal, political, professional, recreational, religious, social).

Organization*

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Role/Title*

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Dates of Service*

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Education/Training/Certificates*

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Have you ever received any awards or honors that you'd like to mention?

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How do you feel Belmont Academy would benefit from your involvement on the Board?*

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If you checked other above, please explain

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Please list any groups, organizations or businesses that you could serve as a liaison to on behalf of Belmont Academy.

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Do you have any potential conflicts of interest in regard to the appointment that you are seeking of which the Belmont Academy Charter School Board needs to be aware of? (For example: Present or potential business relationship with the school; family members employed by Belmont Academy.) *

Answer Required

Yes

If you checked yes above, please describe.

Answer Required

I hereby certify that all statements made by me on this application are correct to the best of my knowledge. I understand that if elected to serve as a Belmont Academy Charter School Board Member that I must complete mandatory background check/finger printing and mandatory Board training. All related costs are at the member’s expense and the position is unpaid.

Signature*

Signature Required

Thank you for applying

Please fix the highlighted areas below before submitting.

Board of Directors Candidate Application