Community Advisory Committee Consideration Form

Partners for Inclusive Communities is maintaining a list of persons who are interested in serving on the Partners Community Advisory Committee. This form can be submitted at any time and it will be kept on file for consideration when positions become available.

First Name:
Last Name:
Organization:
Address:
City:
State:		- - Choose State - - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:
E-mail:
Please state your interest in serving on the Partners Community Advisory Committee-UAMS.
Please list any other particular qualifications or experiences that you feel would benefit the Partners Community Advisory Committee.
Optional: There are categories of membership on the committee to insure broad based representation. Please identify the category or categories in which you may qualify: Individual with developmental disability Individual with other disability Family member of person with disability Representative of state agency/local agency or nonprofit

Contact Us
Partners for Inclusive Communities
David Deere,  M.S.W., M.Th., Director
2001 Pershing Circle, Suite 300 ● North Little Rock, AR 72114
501-682-9900 (V) ● 501-682-9902 (TDD) ● 1-800-342-2923 (V/TDD)
501-682-9901 (Fax)
E-mail us at Partners@uams.edu