<p> UA - Partners for Inclusive Communities</p><p>Community Advisory Committee Consideration Form</p><p>Name: Date Submitted</p><p>Address: </p><p>City: State: AR Zip: Phone: </p><p>E-mail Address (if applicable):</p><p>Please state your interest in serving on the Partners Community Advisory Committee using additional page(s) if needed: </p><p>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:</p><p>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</p><p>Please return this form to: Membership/Nominating Committee Partners for Inclusive Communities-Mann Building 322 Main, Suite 501, Little Rock, AR 72201</p><p>This material is available in alternate formats upon request.</p><p>R. 10/2017 Send questions and requests to David Deere [email protected]; 501-765-6522</p><p>R. 10/2017</p>