COMMITTEE-ONLY MEMBERSHIP APPLICATION

Introduction

Thank you for your interest in becoming a Committee-only member on the Commission on HIV. As a Committee-only member, you will play a vital role in the Commission's work by providing valuable professional expertise to one of our four Committees. This engagement not only fosters greater community participation in the planning process but also ensures compliance with the CDC HIV Planning Guidance. Committee-only members actively contribute to their assigned Committee, leveraging their specialized knowledge and skills. Appointed by the Board of Supervisors, you will have voting privileges within your assigned Committee and will be counted toward the Committee's quorum.

Please complete this Committee-Only Membership Application (Application) in its entirety and submit electronically where prompted. The Application will require approximately 5-7 minutes of your time. If you need any assistance or have questions during the Application process, please don't hesitate to reach out to our Commission staff at hivcomm@lachiv.org or by calling 213.738.2816.

Once your Application is submitted, Commission staff will thoroughly review it for completeness. We will then promptly notify you regarding the next steps in the Application process. If you prefer a paper version of the Application, you may print it it out or contact our Commission staff to have one mailed to you.

Thank you again for your interest in joining the Commission on HIV.

*Questions requiring responses are preceded by an asterisk.

Question Title

* 1. Are you applying as a NEW or RETURNING Committee member?

NEW

RETURNING

Question Title

* 2. Contact Information

Name and Pronoun (For example: "John Smith, he/him/his") *

Do you work for an agency/organization? If yes, please state agency/org name and if not, please indicate "N/A" for not applicable. *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Primary Email Address *

Primary Phone Number *

Question Title

* 3. Were you recommended by an individual or organization? If so, please state the name of the recommending entity. Not required; suggested for applicants representing agencies/organizations

Yes

Recommending individual/organization:

Question Title

* 4. Are you affiliated with a Ryan White Program-funded agency? Affiliated is defined as one who is either a board member, employee, or a consultant of an agency who receives Ryan White Program funding through the Los Angeles County Division of STD and HIV Programs (DHSP). Volunteers are considered unaffiliated. Click here for a list of Ryan White Program-funded agencies; subject to change

Yes

I'm not sure; need assistance to determine

COMMITTEE-ONLY MEMBERSHIP APPLICATION

Introduction

Question Title

* 1. Are you applying as a NEW or RETURNING Committee member?

Question Title

* 2. Contact Information

Question Title

* 3. Were you recommended by an individual or organization? If so, please state the name of the recommending entity. **Not required; suggested for applicants representing agencies/organizations**

Question Title

* 3. Were you recommended by an individual or organization? If so, please state the name of the recommending entity. Not required; suggested for applicants representing agencies/organizations