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Community Engagement Steering Committee Application
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Steps
1.
Step One
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2.
Step Two
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Step One
Community Engagement Steering Committee Application
APPLICANT INFORMATION:
Today's Date:
Today's Date:
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone Number:
Other Phone #:
Email Address:
VOLUNTEER/COMMUNITY SERVICE EXPERIENCE:
Organization:
From / To
From / To Start Date
—
From / To End Date
Role:
Organization:
From / To
From / To Start Date
—
From / To End Date
Role:
EDUCATION
College or University:
Type of Degree or Cert.?
Other Institution
Type of Degree or Cert.?
High School
Diploma? (Yes or No)
REFERENCES:
Reference Name:
Phone #:
Email address:
Relationship:
2nd Reference Name:
Phone #:
Email Address:
Relationship:
How do you see your lived experience contributing to the Community Engagement Steering Committee and PPTNP program?
Continue
Step Two
UNDER THE PUBLIC DISCLOSURE ACT, ALL INFORMATION IN THIS APPLICATION IS SUBJECT TO DISCLOSURE UPON REQUEST EXCEPT THE FOLLOWING INFORMATION IS NOT SUBJECT TO DISCLOSURE: RESIDENTIAL ADDRESSES, RESIDENTIAL TELEPHONE NUMBER, PERSONAL WIRELESS TELEPHONE NUMBERS, AND PERSONAL ELECTRONIC MAIL ADDRESSES.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
I agree.
Electronic Signature
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