Board Service Application & Nomination Form
We at the Humane Society of Chittenden County believe that supporting, strengthening and sustaining the bonds between people and pets improves the well-being of individuals, families and communities. Our mission is to ensure that every pet has a loving home and that every pet owner has access to the resources they need to give those pets happy, healthy lives.
We accomplish our mission by:
•	Sheltering homeless and unwanted animals
•	Placing animals in responsible and caring homes
•	Providing education and resources to schools, community groups and the public
•	Keeping animals with their families through our Surrender Prevention programs
•	Assisting law enforcement with animal cruelty investigations and rescue efforts
•	Partnering with out-of-state high volume shelters to give animals a second chance

Date:   _________________
Nominee: _____________________________________	________________
Address:______________________________________________________
City  ____________________________State:___________Zip:___________
Telephone Numbers (home):  	(work): _________________	
Occupation: _____________________________________________	______
Employer: ____________________________________________________	
Address: _____________________________________________________	
City:  	State:  	Zip:__________

E-mail address: ___________________________________________________________
Nominator Name: ______________________________________________

1.  Why, specifically, are you interested in serving on the HSCC board?

2.  Do you have prior/current non-profit Board experience? If so, please elaborate.

3. What animal welfare issues are of particular interest to you?
4.  Relevant experience and/or employment (please attach resume):
5.  Prior/Current involvement with the HSCC (please check all that apply):

____Adopter  - Year _____		____Relinquished Animal – Year _____

____Attended Events  -  Please list events: ________________________________

____Volunteer   ____At Shelter   ____At an Event   ____Foster Parent

____Donor   ____Monetary   ____In-kind/Supplies

6.  Other volunteer commitments/activities (recent past & present):
7. Please indicate which of the following skills or qualities you believe you possess.
 Skill I can offer the HSCC:		
  Have animal welfare and/or veterinary experience or knowledge		
  Have nonprofit background/can help organization and board increase effectiveness		
  Have a financial management background		
  Have fundraising experience and am willing to actively fundraise		
  Willing to make a financial gift to HSCC that is among top three contributions annually		
  Love of animals		
  Comfortable as organizational "ambassador"		
  Willing to communicate with donors (direct solicitation, signing letters, etc.)		
  Able to adhere to time commitment (5 hrs+/monthly and 3 yr. term)		
  Willing to help plan and execute fundraising events		
  Willing to host house party or other fundraising/awareness event		
  Work in or have substantial knowledge of legal field/issues		
  Willing to plan and execute board "sponsored" events (i.e. annual mtg., donor recog.)		
  Connected to political and influential people in the community, state or nation		
  Willing to help with publicity and public awareness efforts		
  Willing to assist in organizing semi-annual board retreats		
  Willing to serve as a committee chair		
  Willing to consider future term as board officer		
  Willing to help draft and shape policy		
  Willing to help identify prospective donors		
  Have grant writing experience and willing to assist in grant writing		

8.  Other area(s) of expertise/skills/contributions you feel you can make:

9.  All Board members are required to serve on at least one Committee. Please indicate committees in which you might be interested.

Development Committee
Charged with creating an annual development plan that includes priorities, strategy and fundraising goals for board approval, to incorporate into the annual budget.  Also charged with developing strategies to expand relationships with current and potential donors and supporters; defining expectations for board member support and participation in attaining annual fundraising goals; and providing information and resources to assist board members in being active, knowledgeable and effective ambassadors for HSCC.

Budget & Finance Committee
Charged with maintaining financial viability of the organization by keeping the Board aware of financial status; overseeing management of investment portfolio; and assisting the President/CEO with budget development and monitoring.
Governance Committee
Charged with maintaining an effective Board of Directors by continually seeking committed Board members and pursuing board development activities.
10.  During the course of your term, would you be willing to serve in a leadership role?

____Yes	____No
11.  Do you agree to the expectations as set forth in the HSCC Board Job Description?
____Yes	    ____No

Candidate Signature:  	Date: 	

Please return to:

HSCC Nominating Committee
142 Kindness Court
South Burlington, VT 05403

For Board Use:
Done	Activity	Date	
	Nominee has had a personal meeting with CEO, Board Chair, or other Board member		
	Nominee reviews by the committee		
	Nominee attended a Board meeting		
	Nominee interviewed by the Board		
	Action taken by the Board:		
	New Board Member received Board Book