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2026 Board/Committee Member

Please complete this form for all Board or Committee Member positions held during the current year.

Please complete a separate form for each Board or Committee you served on.

If you have any questions while completing this form please contact Anna DiDomenico.

Employee Information

Employee Name

Employee Title

Department or Branch

Date of Service (Start)

Date of Service (End)

Type of Service

Board Member Committee Member

Number of Hours

Describe Service / Activity

Organization Information

CRA Organization

Yes No

Organization Name

Organization Address

Organization Website

Title or Position Held at Organization

Name of Committee

Organization's Purpose/Mission Statement

Upload Mission Statement

If purpose/mission statement is not on website, type purpose/mission statement in box above and upload documentation supporting purpose/mission statement.

Low to Moderate Income Information

If the organization provides services that benefit low to moderate income individuals but it is not clear in the purpose/mission statement, please upload supporting documentation to evidence the benefit to low to moderate income individuals.

Market Area Serviced by Organization

Fairfield County Hartford County Fairfield County and Hartford County Other

2026 Board/Committee Member

Important Notice