District 4 People Fund Representative Application

First Name

Last Name

I am a current resident in good standing with the cooperative of District 4 (Huntington, Penfield, and Wellington townships in Lorain County).

Address

City

Home Phone

Cell Phone

Email Address

Cooperative History

How long have you been an LMRE member?

Employment

Current Employer

Employer Location

Title

Years of Service

Community Involvement

Short Answer

In FIVE SENTENCES OR LESS, please answer the following questions.

What does being a member of a cooperative mean to you?

Why are you interested in representing District 4 on the LMRE People Fund board?

If selected, I will be able to attend four evening meetings, scheduled in January, April, July, and October, as part of my commitment to the LMRE People Fund.

Applicant's Signature

Sign above

Date