BCLI Application for 2018
Name:
Address:
City, State, Zip:
Telephone:
Email:
How did you hear about the BCLI?
What is your gender identity (circle one)? [OPTIONAL]
a)Gender Non-Conforming
b)Genderqueer
c)Man
d)Transgender
e)Woman
f)Not listed above (please specify: ______)
g)Prefer not to disclose
What is your race/ethnicity (circle one)? [OPTIONAL]
a)African American / Black
b)African Born
c)American Indian / Alaska Native
d)Asian / Asian American / Pacific Islander
e)Hispanic / Latino/a/x
f)Mixed Race
g)White (non-Hispanic)
h)Not listed above (please specify: ______)
i)Prefer not to disclose
What is your sexual identity (circle one)? [OPTIONAL]
a)Bisexual
b)Gay
c)Heterosexual/ straight
d)Lesbian
e)Queer
f)Not listed above (please specify: ______)
g)Prefer not to disclose
Do you currently serve on a city, county, or schoolboard or commission?Yes / No
If yes, please list:
What are your top three board or commission seats?(Pleasereferto theattachedseat list for options):
1.
2.
3.
Please include two professional references below:
Name:
Organization:
Title:
Phone Number:
Email:
Relationship (former or current):
Name:
Organization:
Title:
Phone Number:
Email:
Relationship (former or current):
Nominator (person writing your letter of recommendation):
Name:
Organization:
Title:
Phone Number:
Email:
Relationship (former or current):
Your nominator is a…
a)Labor Organization or Union
b)Policy Advocacy Organization
c)Community-Based or Grassroots Organization
d)Faith-Based Organization
e)BCLI Alumni
f)Other: ______
Please also include:
- Letter of recommendation from your nominator(Nominator should email it directly to ). This letter should include why the organization believes the applicant:
- Would a good fit for the program
- Has shared values with the nominating organization
- Has advocated withlow-income communities, communities ofcolor, workers, and other underrepresented communities in the past
- Would be a good future (or current) board member or commissioner
- Your letter of interest. Thisletterof interest shouldinclude:
- Explain how you have advocated with low-income communities, communities ofcolor, workers, and other underrepresented communities in the past
- Anyequity, socialjusticeandcareer aspirations you possess
- Why you are interested in and would be a good candidate for each of the top three identified board or commission seats you listed on your application
- Describehow you will continue to remain committed and accountable to the community throughout your work, especially if you become a board member or commissioner.
- Your most recent resume.
All materials (application, nomination letter, letter of interest, and resume)
aredue Sunday, October 1, 2017 at 11:59pm online or via email:
Formoreinformationabout BCLI, contact Ana Laura Martínez at .
More information aboutCenter on Policy Initiatives canbefoundat www.cpisandiego.org.