2019 Partners Provider Council Voting Membership Form of Interest

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

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* 2. Is your agency interested in being a voting member on Partners Provider Council?

Yes, I am interested in being a voting member on the council.

No, I am not interested in being a voting member on the council.

I am unsure about being a voting member on the council.

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

Representative:

Alternate:

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

MH

IDD

SU

TBI

Hospital

Other (please specify)

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* 5. The council will have 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 send alternate representatives and/or call-in to meetings.

I understand and agree to the attendance requirements.

I do not understand or agree to the attendance requirements.