Protection and Advocacy for Individuals with Mental Illness (PAIMI) Advisory Council Application

Protection and Advocacy for Individuals with Mental Illness (PAIMI) Advisory Council Application
Name*

First NameLast Name
Phone Number (Home)

Area CodePhone Number
Phone Number (Cell)*

Area CodePhone Number
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Occupation
Agency or Organization
If Applicable
Phone Number (Work)

Area CodePhone Number
Phone Number (Fax)

Area CodePhone Number

Demographics

In order to achieve diverse representation on the PAIMI Advisory Council, we would appreciate your response to the following questions.
Sex

MaleFemale
How would you describe yourself? (Select all that apply)

AsianBlack, not of Hispanic/Latino originHispanicNorth American Indian or Alaskan Native/IndigenousPacific IslanderWhite, not of Hispanic/Latino OriginOther

Demographics