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* 1. What provider agency/organization do you represent at Partners Provider Council?

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* 2. Are you currently a voting member of the Partners Provider Council?
Please Note: If you are currently a voting member, you do not need to complete this form. This form is for new additions to the Provider Council only.

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* 3. Please write the names and email addresses of two staff members who would be representing your agency at Provider Council meetings:

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* 4. The agency that I represent provides the following type(s) of services: Check all that apply.

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* 5. Please check the boxes of the counties you currently serve. Check all that apply.

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* 6. Describe your interest in participating in the Provider Council:

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* 7. The council typically holds ten meetings per year. Council member agencies must maintain adequate attendance throughout the year meaning agencies will not miss more than two consecutive meetings or more than four meetings in a 12-month period. Agencies are permitted to have an alternate representative attend meetings and attend via phone or Zoom.

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