State Rehabilitation Council
"working with the Office of Rehabilitation Services to maximize the potential of people
with disabilities through meaningful employment....    

SRC Membership Application

If you have any questions about the application process, please call Nancy Baker, Consultant for the Council, at 401.421.7005 ext. 311.
If you would like to be considered for appointment to the State Rehabilitation Council, please complete the following application:

IDENTIFICATION DATA

Name:

Email:

Work Phone:       Home Phone:    Cell Phone:

Home Address: (Street, City, State, Zip):

Business Address: (Street, City, State, Zip):

EDUCATION

Last School Attended :

Dates Attended: to

Areas of Specialization:

EMPLOYMENT

Two Most Recent Employers:

Firm:
Position:
Dates: to

Firm:
Position:
Dates: to

BUSINESS & PROFESSIONAL ORGANIZATIONS (Include business directorships)

Please list current or recent affiliations:

Organization:
Office Held:
Dates: to

Organization:
Office Held:
Dates: to

Organization:
Office Held:
Dates: to

CIVIC, CHARITABLE, OTHER ORGANIZATIONS

Please list current or recent affiliations:

Organization:
Office Held:
Dates: to

Organization:
Office Held:
Dates: to

Organization:
Office Held:
Dates: to

WHAT DO YOU FEEL ARE YOUR STRONGEST AREAS OF EXPERTISE BASED ON YOUR BACKGROUND AND EXPERIENCES?

Medicaid Fund Raising Vocational Rehabilitation Public Relations
Planning Marketing Government Relations Special Education
Legal Affairs Assistive Technology
Other (specify)

INDICATE PRIMARY AREAS OF INTEREST OUTSIDE YOUR AREA OF EXPERTISE:

Medicaid Fund Raising Vocational Rehabilitation Public Relations
Planning Marketing Government Relations Special Education
Legal Affairs Assistive Technology
Other (specify)

THE FOLLOWING ARE OPTIONAL:

Age: 20-35 36-50 51-65 Over 65

Ethnicity: Black White Asian Native American Hispanic Other (specify):

Sex: Female Male

PLEASE DESCRIBE YOUR DISABILITY:

Thank you for your application. You will be hearing from a member of the State Rehabilitation Council soon.

Please fill out and return form to:
SRC
C/O Office of Rehabilitation Services
40 Fountain Street
Providence, RI 02903