McDowell County Opioid Settlement Fund Review Panel Interest Form
Thank you for your interest in joining the review panel. Please complete this form to confirm your eligibility and share your qualifications. Note that all voting panel members must remain impartial and cannot have applied for funding or be affiliated with any applicant that has applied for funding.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
County of Residence
Organization affiliation(if any)
Have you personally applied for any McDowell County Opioid Settlement Funding?
Yes
No
Are you affiliated in any way with an organization or individual who has applied for funding from the McDowell County Opioid Settlement Funds?
Yes
No
If previous answer is yes please explain
Do you agree to disclose any potential conflicts of interest if they arise during your service on the voting panel?
Yes
No
Are you willing and able to commit the time required to review applications and participate in voting panel meetings in order to complete the voting process by the proposed deadline?
Yes
No
Share what qualifications or experience makes you qualified to participate in this voting panel.
By submitting this application, I certify that the information provided is true and accurate to the best of my knowledge. I understand that misrepresentation of eligibility or conflicts of interest may disqualify me from serving on the voting panel.
Submit
Submit
Should be Empty: