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134 East Rossi Road 831-970-9252 Salinas, CA 93901 Facsimile: 831-775-5053

I have read and accept the Board Responsibilities and understand what is expected of me should I be elected to the MCHI Board of Directors. Yes � No

Organization Representation

Name of Organization: Street Address:

City: ZIP: Organization's Mission Statement:

Your functional title/role at the organization:

Organization's Service Area:

MCHI shall confirm via email as to whether you satisfy HUD's parameters of what constitutes an elected representative of a low-income neighborhood organization. It is assumed that you shall be able to provide at a later date signed election rosters and minutes of the election meeting.

Industry Employed in: Occupational Description

Name: Date: Home Address:

City: ZIP: Home Phone: Mobile Phone:

Business Phone: Email:

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Do any family members living with you have a disability? : Yes � No � Are there any family members in your household older than 62? : Yes � No � Have you ever lived in a federally subsidized housing unit? : Yes � No � Briefly state why you are interested in serving on the MCHI Board and what you believe you will gain from the opportunity: Have you served on another Board? : Yes � No � If yes, indicate your experience: Highest level of education attained (for statistical diversity):

Less than High School Bachelor's

GED Master's

High School Graduate Professional

Some College Doctor's

Associate

Ethnicity (for statistical diversity):

Check one: Check one:

White Hispanic or Latino

Black/African American Not Hispanic or Latino

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

Sex (for statistical diversity): Male � Female �

* * * * * Thank you again for expressing an interest in MCHI and its goals for affordable housing in Monterey County. You can expect to hear from MCHI's Executive Director within days of your submitting this application.