Council Member Application

First Name*

Last Name*

Street Address*

City*

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

Type of Disability

Other Gender Identification

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