Contact Information

Please complete this application form if you would like to be considered for the Citizen Advisory Council in your area.

If you need translation or other assistance completing this form please contact Patti Becker, Manager of Community Partnerships, at or 608-210-3704.

If you need to leave before finishing this survey, be sure to click the "Next" button at the bottom of the page before exiting to ensure your answers are saved. When you return to the survey, you will be on the page where you left off. You can press the "Back" button to review your answers before submitting your finalized application.

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* 1. Contact Information

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* 2. What is the best way to get in touch with you?

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* 3. What is the best time to contact you?