EmailMe Form - FIFEC Board Member Application

FIFEC Board Membership involves dedicating hours of volunteer service throughout the year, as well as at the annual conference. If you are uncertain about your commitment and ability to devote the necessary time and effort, please consider applying when you are able to fully commit. If you are certain about your commitment, please proceed with completing your application.

Candidate's Name (Preferred) *

Job Title *

Employer's Name *

Employer's Full Address *

Does your employer support your participation as a FIFEC board member *

Yes

No

Not Sure

Retired

Conference participation normally involves a 3-night stay at the host hotel. Will your employer cover your hotel expenses while assisting at FIFEC? *

Primary Phone *

### - ### - ####

Other Phone

### - ### - ####

Email Address *

Years in the Industry *

Please list the roles you've held in the industry (Insurance Company, Law Enforcement, Attorney, etc). *

If you are a member of another organization, please list the name, your role/title. and how long you've served. *

Why are you interested in joining FIFEC's Board? *

Please indicate the subcommittees on which you'd be interested in serving. *

How would you contribute to FIFEC and its education mission? *

If you were referred to FIFEC, please enter the individual's name. *

Please list reference 1: Name, Company, Phone and Email *

Please list reference 2: Name, Company, Phone and Email *

Have you ever had an administrative action filed against you? *

Yes

No

Have you ever been convicted of or plead nolo contendere to a crime? *

Yes

No

Have you ever been convicted or plead nolo contendere to a moral turpitude charge? *

Yes

No

If you replied "Yes" to any of the above questions, please provide additional information.

By checking the box below you certify that your answers are true and correct to the best of your knowledge. Any false or misleading information provided in this application or during any membership consideration interviews may result in release from this organization. If considered for membership you must serve a one-year probationary period, after which your membership status will be decided based on your performance during the probationary period, and your agreement to abide by the FIFEC bylaws.
I further certify that I have not been convicted of a crime involving moral turpitude.

I acknowledge that volunteering on the FIFEC board involves dedicating many hours throughout the year in addition to the conference and that I am willing to commit to the necessary time to fully commit to the board.

I further understand that any membership offer is contingent on my review of the FIFEC bylaws and my agreement to abide by those bylaws. If considered for membership, I understand that I must serve a one-year probationary period and that my membership will be voted on after said probationary period.

Acknowledgment *

I acknowledge and agree to the terms stated above.

Date *

MM / DD / YYYY

Candidate's Full Legal Name *

Candidate's Signature *

Clear