IDD Services Advisory Committee (IDDSAC) Application Form

2. Please complete the online form below.

   Please complete the online form below.

4. PERSONAL INFORMATION

6. First Name*

7. Last Name*

9. Street Number

10. Street Name

11. Street Type

12. Apt #

14. City

15. State

16. Zip

18. Sex:*

    1. Male
    2. Female

19. Primary Phone Number:*

20. Alternate Phone Number:

21. Email Address:*

23. Occupation:*

24. Employer*

26. RESIDENCY

28. Length of Residency in Bexar County:*

29. Are you a registered voter:*

    1. Yes

    1. No

31. SPECIAL EXPERTISE

    Please check all that apply

    1. Advocacy
    2. Practitioner
    3. Administration
    4. Business/Financial

    1. Legal
    2. Political/Government Process
    3. Medical

    1. Planning
    2. Managed Care
    3. RFP Bid Process

    1. Contract Management
    2. Research/Program Evaluation
    3. Community Development
33. Potential Committee Member Type*

    Please check all that apply

    1. Consumer/LAR/Family Member
    2. Community Member
35. Describe your interest in serving on the advisory committee

37. Describe how you learned about this committee

39. ORGANIZATION MEMBERSHIP

41. Are you currently serving on other Boards, Commissions, or Committees?*

    1. Yes

    1. No

43. If yes, which:

45. Have you served on a Board, Commission, or Committee before?*

    1. Yes

    1. No

47. If yes, which:

49. Please list organization memberships and positions held:

51. Please List Areas of Special Interest/Other Information for Consideration

53. RESUME

55. Upload Resume

56. OR

57. Enter Basic Resume Information Below

59. CONFLICT OF INTEREST

61. Please list all potential real or perceived conflict of interest by serving on this committee:

63. By submitting this application I acknowledge and understand that membership on the IDD Services Advisory Committee (IDDSAC) requires commitment on my part, to complete all necessary members training, attend committee meetings, and to complete committee work projects timely. I will put great effort into understanding the issues coming before the committee, use my knowledge and experience toward the best interest for the people AACOG serves. I similarly acknowledge that the contributions of the committee members have a significant impact on the current and future business of AACOG and services to the citizens of Bexar County.

    By submitting this application I acknowledge and understand that membership on the IDD Services Advisory Committee (IDDSAC) requires commitment on my part, to complete all necessary members training, attend committee meetings, and to complete committee work projects timely. I will put great effort into understanding the issues coming before the committee, use my knowledge and experience toward the best interest for the people AACOG serves. I similarly acknowledge that the contributions of the committee members have a significant impact on the current and future business of AACOG and services to the citizens of Bexar County.

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65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

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