UA - Partners for Inclusive Communities

Community Advisory Committee Consideration Form

Name: Date Submitted

Address:

City: State: AR Zip: Phone:

E-mail Address (if applicable):

Please state your interest in serving on the Partners Community Advisory Committee using additional page(s) if needed:

Please share any other particular qualifications or experiences with disability that you feel would benefit the Partners Community Advisory Committee using additional page(s) if needed:

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 a developmental disability ☐Individual with other disability ☐Family member of an individual with disability ☐Representative of state agency, local agency or nonprofit agency

Please return this form to: Membership/Nominating Committee Partners for Inclusive Communities-Mann Building 322 Main, Suite 501, Little Rock, AR 72201

This material is available in alternate formats upon request.

R. 10/2017 Send questions and requests to David Deere [email protected]; 501-765-6522

R. 10/2017