The IAL - Board of Directors Application

IAL Website - Board of Directors Application

The IAL - Board of Directors Application

Personal Information
Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Birth Date / MM / DD YYYY
Home Phone - (###) - ### ####
Office Phone - (###) - ### ####
Email
Laryngectomized? Yes No
If yes, Date of Laryngectomee? / MM / DD YYYY
Education
School
Location
Start Date / MM / DD YYYY
End Date / MM / DD YYYY
Did you Graduate? Yes No
Degree Acheived?
Employment Record
Company or Organization
Position
Address
Duties
Company or Organization
Position
Address
Duties
Are you currently employed? Yes No Retired
Clubs and / or Fraternal Order Activities
Name First
Office
Position
Date / MM / DD YYYY
Other Activities
IAL Activities
Have you ever been an IAL Officer? Yes No
Position
Date / MM / DD YYYY
Have you ever been an IAL Board Member? Yes No
Date / MM / DD YYYY
Committee Assignments?
Other Information
1. What positions have you held or are holding in your community?
2. Have you attended a Voice Institute? Yes No
When? / MM / DD YYYY
3. Have you attended an IAL Annual Meeting? Yes No
When? / MM / DD YYYY
Where?
4. Have you taught speech to other laryngectomees? Yes No
Where?
How qualified?
5. Have you been involved with the American Cancer Society? Yes No
If yes, position and / or activities?
6. Do you have any hobbies, special interests, or talents? Yes No
If yes, what?
7. Please Submit letter of club's endorsement.
References: (One should attest to speech proficiency)
1.
2.
3.
Note: Please enclose (2) 2 1/2 x 4 photographs. Also, please submit additional information on separate sheet if necessary.

Please Initial

The IAL - Board of Directors Application

The IAL - Board of Directors Application

Personal Information

Education

Employment Record

Clubs and / or Fraternal Order Activities

IAL Activities

Other Information

7. Please Submit letter of club's endorsement.

References: (One should attest to speech proficiency)