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* 1. Contact Information

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* 2. What is the best email to use to send important documents?

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* 3. What is the best phone number to contact you in case of an emergency?

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* 4. Please check the box for your status of board/committee

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* 5. Which committee are you interested in serving on? (Check all that apply)

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* 6. What Committee seat will you represent?

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* 8. Letter of Interest (LOI) -
Please provide an explanation of your interest and relevant experience to support serving on a committee for the OHA EMS and Trauma Systems program.
Put N/A if you choose to submit a document instead of writing a response here. (Q8)
* A LOI is required to be considered for appointment to a committee.

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* 9. Submit Letter of Interest document.

PDF, DOCX, DOC file types only.
Choose File

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* 10. Upload a Resume or CV that includes your experience and expertise to support your role on the board or committee.
*A resume or CV is required to be considered for appointment to a committee. If you are unable to upload the document please submit it to  EMS.TRAUMA@dhsoha.state.or.us

PDF, DOCX, DOC file types only.
Choose File

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* 11. Which race/ethnicity best describes you? (Please choose only one.)
*To better assist us in meetings our affirmative action objectives, we would appreciate information about your background and gender identity. This information is optional and is used for data collection only. Under state and federal law, this information may not be used to discriminate against you. 

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* 12. What is your gender identity?
*To better assist us in meetings our affirmative action objectives, we would appreciate information about your background and gender identity. This information is optional and is used for data collection only. Under state and federal law, this information may not be used to discriminate against you.

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