Board Application Please enable JavaScript in your browser to complete this form.Are you a member of FFRF nationally? *You must be a member in good standing with FFRF to be on the FFRF-VS board. Register HERE.NoYesHow many years have you been an FFRF member (roughly)?Name *FirstLastPreferred pronouns (optional)Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *EmailConfirm EmailPhone *Title/OccupationBackground *Professional and/or Community Service Activities (Include date(s) of service, and title of office(s) held, if applicable)Interest *Statement of Interest (Describe why you are interested in serving on the FFRF-VS Board)Securities Convictions *Have you ever been convicted of a felony involving a transaction in securities, consumer fraud or antitrust in any state or federal jurisdiction within the past seven years?NoYesFraud Convictions *Have you ever been convicted of a felony the essential elements of which consisted of fraud, misrepresentation, theft by false pretenses or restraint of trade or monopoly in any state or federal jurisdiction within the past seven years?NoYesJudgements *Have you ever been subject to an injunction, judgment, decree or permanent order of any state or federal court entered within the last seven years involving any of the following: a. The violation of fraud or registration provisions of the securities laws of that jurisdiction; b. The violation of the consumer fraud laws of that jurisdiction; c. The violation of the antitrust of restraint of trade laws of that jurisdiction?NoYesBankruptcy *Have you ever served on a board or held a beneficial or membership interest in a corporation, or held a twenty per cent interest in any other corporation on the bankruptcy or receivership of the corporation?NoYesSubmit
