Application for Board Membership
QC Plus 60 Club
| Name: | Date: | |||||||||||
| Address: | Street: | City, St, Zip: | ||||||||||
| Home Phone: | Cell Phone: | |||||||||||
| E-Mail: | ||||||||||||
| Retired: | Yes _____ No _____ | Where employed: | ||||||||||
| Plus 60 Member: | Yes _____ No _____ | If yes, how long? | ||||||||||
Plus 60 activities in which you have participated:
List organizations/clubs and offices/committees in which you have served:
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Organization/Club |
Office held or Committee |
What experiences or interests could you contribute to the Plus 60 Board?
Why would you like to serve as a Plus 60 Board member?
Thank you for considering membership on the Plus 60 Board.
Please return the completed form by mail or e-mail to:
Dick Stoltz, 411 4th Ave. West, Andalusia, Illinois 61232
Questions? please call Dick @ 309-798-2140