SWORD Non-Voting Member Interest Form

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1. Contact Information w 0

Name

Business/Organization

Business Address

County

City/Town

Years with current business/organization

Position at your organization

Email

Best phone to contact you

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2. Please check the categories that best describe you. w 0

Behavioral health provider

Health care provider

Recovery/treatment expert

County or city representative

Tribal representative (can be appointed by Council with no application needed)

Community representative

Lived experience with the opioid crisis

Other (please specify)

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3. Why do you want to serve on the SWORD? w 0

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4. How will our region benefit from your participation on the SWORD? w 0

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5. Please list any conflicts of interest you might have participating on the SWORD. w 0

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6. You've completed the interest form. Your last step is to email a short bio or resume listing at least one professional or personal reference. If your LinkedIn profile is up to date, you can include the link instead of a resume or bio.

Email to west.claire@outlook.com or mail hard copies to Region 9 EDD, 135 Burnett Drive, Unit 1 Durango, CO 81301. Thank you. w 0