Applicant InformationHelp us learn a little bit about you!Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are you over the age of 18?(Required) Yes No Are you currently employed?(Required) Yes No Please list your current employment information:(Required)Job TitleEmployer NameLength of Time at Job Add RemoveHave you ever been convicted of a felony?(Required) Yes No If you answered yes to the above question, please describe.Are you prepared to commit to a two (2) year term of volunteer service to PFIC Network?(Required) Yes No Would you describe yourself as any of the following: PFIC Patient PFIC Parent PFIC Family Member or Caregiver Friend of PFIC Patient Clinician or Healthcare Provider PFIC Scientist or Researcher Pharma/Biotech Industry Representative Rare Disease Advocate Supporter of PFIC Network Please check any that may apply. These are not requirements for board membership.Board Service InformationHelp us understand why you are interested in joining us and how we can help you best utilize your skills and passion to help PFIC patients and families.Why are you interested in serving on the PFIC Network Board of Directors?(Required)Areas of Expertise(Required) Advocacy/Outreach/Awareness Board Governance Business Operations Community Service or Organizing Education / Instruction Event Planning Finance /Accounting Fundraising Graphic design Grant writing Healthcare Leadership/Management Legal Marketing Mental Health Services Nonprofit Experience Personnel / Human Resources Policy Development Science/Research Social Media / Communications Strategic Planning Website/Technology Youth Programs / Events Other Please check all areas of contribution you feel you can make to help further PFIC Network’s missionPlease describe any experience or expertise you have that is relevant to PFIC Network's mission.(Required)Do you have previous experience serving on a board or committee?(Required) Yes No Examples include business, civic, community, fraternal, political, professional, recreational, religious, and social organizations.Please list your previous board or committee experiences.Organization NameRole/TitleDates Served Add RemoveHow do you feel PFIC Network would benefit from your involvement on the board?(Required)Please share any other information you feel important for consideration of your application to serve as a board member:I attest that the information I have provided above is true and correct, to the best of my knowledge.(Required) Yes No
