Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer (if applicable)
Type of work performed
What experience, personal or professional, have you had with people with people with disabilities or disability issues?
*
Do you have a current or past experience with the five Centers for Independent Living or SILC in Connecticut? If so, what is your affiliation?
*
Do you have a current or past experience with the five Centers for Independent Living or SILC in Connecticut? If so, what is your affiliation?
*
Please describe any involvement you have had with any nonprofit boards, committees, and volunteer activities.
*
Why are you interested in serving on the CT SILC?
*
Please upload a current resume here or email to Michele DuBois michele@ctsilc.org
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