Name ____________________________________________  Phone _______________________________________

Address ________________________________________________________________________________________

City _______________________________________   State _______________________  Zipcode ________________

Email Address _________________________________________________

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Children currently enrolled at Children's Place

1. __________________________________     3. ____________________________________

2. __________________________________     4. ____________________________________

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Please provide the following information for your current and your last employer:

1.  CURRENT:   Name of Employer ______________________________________________    Title _____________________________________

                             Date of Employment _____________________________________________    Phone ___________________________________

2.  PREVIOUS  Name of Current Employer ______________________________________  Title _____________________________________

                            Date of Employment _____________________________________    Phone ______________________________________

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Please provide two character references.  By completing this section you are authorizing Children's Place to contact these individuals and also authorizing the individuals to provide information regarding you and releasing them from all liability in connection with the release of this information.

1.  _____________________________________   phone _____________________________________

2.  _____________________________________    phone _____________________________________

List all Education, including schools and degrees earned:

Please answer the following questions:

1.  Describe why you are interested in serving on the Board of Directors:

2.  Describe your experience or skills that would be an asset to the Board of Directors:

3.  Describe any other civic, professional, or volunteer activities or affiliations:

4.  Describe any prior experience or expertise in the fields of education, finance, personnel or business management.

I certify that information provided by me in connection with this application is true and accurate.  I understand that any misrepresentation or omission of facts is sufficient cause to reject my application and cause my removal from the Board of Directors if selected.  I understand that serving on the Board, I will hear and be a part of decision making and many of the items discussed are confidential and should not be talked about outside of the board room.

 Name __________________________________________________  Date _______________________________________