Affiliate Foundation Board Member Information Form

Contact Information

First Name*

Last Name*

Recognition Name*

The name you would like to be called and would like used on our website and printed materials.

Title*

If you selected Other, please provide title here.

Affiliate Community Foundation*

Address 1*

Address 2

City*

State*

Zip*

Primary Phone*

Primary phone type*

Email Address*

Spouse/Partner Name

Professional Information

If you are a professional advisor, please select the option below that best suits your role. *

Do you work for a nonprofit organization that may apply for or receive funding from NCCF?*

Yes No

If yes, please name the organization:

Additional Information

Preferred Pronouns

If you selected other, please list your preferred pronouns

Race

If you selected other, please list your race

Conflict of Interest and Confidentiality Policies

By submitting this form, I agree to NCCF's Conflict of Interest Policy and Confidentiality Policy which are found on the home page of the portal.

Publicity Release

By submitting this form, I permit the North Carolina Community Foundation to use my name and image for publicity and/or educational purposes, including but not limited to use on NCCF’s website and social media, in news releases sent to media outlets, in videos, photos and/or printed materials. If you have questions or would like to opt out, please contact your community leadership officer.