First Name *
Last Name *
Street Address *
City *
State *
Postal Code *
Phone *
Email *
In the space provided below, indicate why you are interested in serving on the council. *
In the space provided below, what previous experience, areas of interest or skill areas do you have that would lead to logical work on committees? Examples of some NYSILC committees include Monitoring & Evaluation, Public Policy, Emergency Preparedness, Development, Finance, State Plan, Recruitment, Consumer Satisfaction and Needs Assessment. *
In the space provided below, what affiliations do you have with other national, statewide, and regional groups, especially related to people with disabilities? *
Please provide a name, relationship, phone number, and email of your Professional Reference *
Please provide a name, relationship, phone number, and email of your Personal Reference

Please provide us with some background information about yourself:

Are you a person with a disability? (Check one)
Yes.
No.
If yes, please identify your general disability type: (Check one)
Physical.
Sensory (Hearing/Vision).
Cognitive.
Behavioral/Mental Health.
Multiple Disabilities.
Other.
If selected other, please specify:
What is your race/ethnicity? (Check one)
American Indian/Alaskan Native/Indigenous Person.
Asian.
Black/African American.
Hispanic/Latino/Latinx.
Native Hawaiian/Pacific Islander.
White/Caucasian.
Two or more races.
Race/ethnicity unknown.
Other.
If selected other, please specify.
What is your gender/how do you identify? (Check one)
Female.
Male.
Non-Binary.
Other.
If the designations are inadequate, please tell us your preferred identification below:
What is your age within a selected range? (Check one)
18-28.
29-38.
39-48.
49-58.
59-68.
Above 69.
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