Board Application Name Information If you would prefer to fill the application in any other format such as (Word, Pdf, verbally, etc), please contact us at: Local Phone: (850) 487-3278 Toll-Free 1-844-FL-FAAST (353-2278) Fax: (850) 575-4216 Email: info@faastinc.org Applicant Title Choose One Mr. Ms. Mrs. Prof. Dr. Preferred Pronouns he/him/his she/her/hers them/they/their Other/Not Listed First Name * Last Name * Email Address * Contact Number * Address Address Address 2 City/Town State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Upload CV Add File Please upload your CV in PDF format. Current Employer Current Employer Contact Number * Address Address 2 City/Town State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Reference Reference * Contact Number * Email Address * Address City/Town State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Additional Information Representation Categories * Individual who has a disability that uses assistive technology Family member/legal guardian of an individual who has a disability that uses assistive technology A representative of a consumer organization concerned with assistive technology A representative of business or industry concerned with assistive technology A representative of a Florida state agency Applicants must represent ONE (1) of these categories Availability Monday-Friday between 9:00 a.m.-5:00 p.m. EDT * I am available for virtual meetings. I am available to travel for in-person meetings and events. Evenings and Weekends (outside of the window stated above) * I am available for virtual meetings. I am available to travel for in-person meetings and events. Demographics and Skills Committees you would like to be a part of * Technology and Public Awareness Public Policy and Advocacy & Interagency New Horizon Loan Program Service Delivery Racial and Ethnic Identity * American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to disclose Do you identify as an individual who has a disability? * Yes No Prefer not to disclose Are you a Veteran? Yes No Gender Identity * Male Female Transgender Female Transgender Male Gender Neutral Nonbinary Agender Pangender Genderqueer Two-Spirit Third Gender All None Not Listed: ___________ Prefer not to disclose Age * Younger than 18 18-24 25-34 35-44 45-54 55-64 65-74 75-84 Older than 85 Prefer not to disclose Knowledge Please select your knowledge level for each item below. 1 star = Not Knowledgeable, 3 = Moderately Knowledgeable, 5 = Very Knowledgeable Advocacy * Business Management * Creating Business Opportunities * Dedication/Responsiveness * Educational Development & Delivery * Legal Implications for Nonprofits * Strong Professional Networks * Grant Management * Government Relations Research * Strategic Planning * Financial Accounting in Nonprofits * Visionary * Clinical Skills (including assistive technology assessments) * Ethical Practices * Nonprofit Governance * Organizational Development * Public Speaking * Social Media/Networking * Emerging Technologies * Leadership Capability * Have you previously served on a nonprofit board of directors? * Yes No Other Other: List any boards, councils, commissions, and/or committees in which you have served. (Please included the dates of service) * Describe your experience with assistive technology devices and/or services? * Why would you like to serve on the ATAC/FAAST Board? * Anything else you’d like FAAST to know? Information Summary
