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2025 Kansas Governor’s Council on Wellness

Appointments Questionnaire

This Questionnaire is to be fully completed by each appointee. Please answer each question completely to the best of your knowledge. If a question is not applicable, please mark “N/A”. Contact Abigayle Jackson at ajackson@dccca.org or Ext- 4033 if you have questions when completing the form.

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1.General Information
(please include title and middle name along with any names previously used)

Full Name:

Street:

City

State:

Zip Code:

County:

2.BUSINESS ADDRESS

Name of Business:

Street:

City

State:

Zip Code:

County:

Position Title:

Home Phone:

Business Phone:

Cell Phone:

Fax:

Email:

3.Kansas Resident?

Yes

No

4.Ethnic/Cultural Background:

White/Caucasian

Asian

Native Hawaiian or Pacific Islander

Hispanic or Latino

African-American

Native American

Prefer not to provide

Other (please specify)

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