LATAN - Louisiana Assistive Technology Access Network

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*Board Member Prospect:
*Home Street Address:
*Home City:
*Home State:
*Home Zip Code:
Employer:
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Work Street Address:
Work City:
Work State:
Work Zip Code:
*Email:
Fax:
Home Phone Number:
Work Phone Number:
Cell Phone Number:
Parish:
Parish Type:	Rural Urban Suburban
Special Skills:	FundRaising/Development Business/Management Computer Technology Program Support/Evaluation Personnel/Human Resources Marketing/PR Governance	Nonprofit Board Experience Finances/Accounting Legal Planning Assistive Technology Other
Professional Position:	Legislator Media Leader Leader of High Profile Company Minister of High Profile Church Nonprofit Leader Other
In order to help us assure a diversity of individuals on the LATAN Board of Directors, we would appreciate your giving us this optional information.
Gender:
Age:
Ethnicity:
Which best describes you (check all that apply)?:	AT User Individual with disability Individual with functional limitation Parent/Family Member Advocate Business Leader Community Leader Interested Individual
Please list your community efforts, volunteer leadership positions, current commitments, other characteristics and qualities you will bring to the board if elected, and/or other information that you believe would be helpful to our nominating committee.

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