Citizens Advisory Committee

As an applicant for the Advisory Committee, your name, address, and phone number may be available to the press and the public.

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1. Applicant Information

Name

Company

Address

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

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2. Occupation (if retired, please indicate former occupation or profession)

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3. What qualities or qualifications do you have that would help you serve on this advisory committee? (Please consider your personal experiences, work experiences, educational experiences, ability to work with a group, community work, ability to understand an entire system and anything else you think may be important.)

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4. Additional pertinent information/references

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5. I am interested in serving as a: (select from options below)

Provider

Consumer

Citizen

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6. How did you hear about this opportunity? (or, who referred you?)