2010 Committee Interest Form

1. Introduction

If you have not already submitted your 2010 Committee Interest Form and would like to participate on an FHCA member committee council, please indicate your first and second top preferences by marking a [1] and [2] in your committee(s) of choice below. Certain committees are limited by the Bylaws to one representative per district or region, and others have practical size limitations. FHCA's President will do her best to accommodate your preference. Associate members on FHCA committees will be designated by the AMSC Chair. Please complete this form by August 6, 2010.

Question Title

* 1. Please provide us with your contact information

First and Last Name:

Company/Facility:

Address:

Address 2:

City:

State:

ZIP:

District:

Email Address:

Phone Number:

Question Title

* 2. Please indicate your first and second preferences for participating on a committee or council by ranking your first and second choice in the boxes from the list below.

Annual Conference

Budget & Finance

Bylaws & Credentials

Florida Center for Assisted Living

Legislative

Professional Development

Reimbursement

Rules & Regulation

Culture Change Council

Emergency Preparedness Council

Question Title

* 1. Please provide us with your contact information

Question Title

* 2. Please indicate your first and second preferences for participating on a committee or council by ranking your first and second choice in the boxes from the list below.

Question Title

* 3. Please indicate your experience/background that you feel would be helpful to FHCA in assigning you the committee preference(s) you indicated.