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* 1. Name

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* 2. Address

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* 3. Phone number (including area code)

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* 4. E-mail address

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* 5. Gender

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* 6. Ethnicity (optional)

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* 7. Occupation

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* 8. Nomination by

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* 9. Application Category: We are now only accepting applications for the Consumer Representative position.

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* 10. Please provide a brief statement of qualifications that highlights the relevant skills and experience you would bring to the Alzheimer's Advisory Committee.

In addition, please answer these questions:

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* 11. Briefly describe the interests you will represent and what you hope to contribute as a result of participating on the Alzheimer's Advisory Committee.

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* 12. What are the central Alzheimer's issues you would recommend the committee consider and why?

* Please note the 2021 Alzheimer's Advisory Committee Meeting Dates:
March 11th, June 10th, September 9th, and December 9th, 2021

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* 13. Signature of the person completing this form.
**Typing in your full name below is considered equivalent to a signature.

Signature of a personal assistant is acceptable.

Click done to submit your application.

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