First Name:            Last Name:     

Address:        City:        OK    Zip:      

Phone Contact   
    Home:        Work:       Mobile:      

Email Address:   

 
   Employer and Contact Information

Employer:            

Address:          City/State/Zip code:   

Phone:        Fax: 
 
 
Are you the Parent of a Child/Children with a Disability/Disabilities?    Yes     No
 
Child/Children's Age(s):      Child/Children's Disability: 
 
Consumer Services:   Yes    No                     Family Member:     Yes    No

Have you served on other advisory panels or boards?  If so, please list:
    
       1.   
       2.   
       3.   
       4.   
       5.   

Do you belong to any organizations?  If so, please list: 

       1.   
       2.   
       3.   
       4.   
       5.   

What special interest/skills do you bring to the board?  Please list:

       1.   
       2.   
       3.   
       4.   
       5.   

Would you like to share any other information with us?  Please share: