211US Steering Committee Membership Application 2017

Name

First Last

Title

Organization

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone

Cell Phone

Fax Number

Email

Affiliation: Please check all that apply

What is your professional role(s) in the 2-1-1 structure? Is it at the local, state, and/or national level(s)?

What strengths, skills and knowledge can you bring to the 211US Steering Committee? Please check all that apply.

Describe the strengths, skills and knowledge checked off in previous question.

How would describe your personal style? Please check all that apply.

Why do you want to serve on the 211US Steering Committee?

What are your areas of expertise? Please check all that apply.

Have you previously been involved in the national efforts for 211US and if so, in what areas?

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