Identification Data
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If you would like to be considered as a member of RICAT,
please complete the following information:
NAME:
Work Phone:
Home Phone:
Cell Phone:
Email:
Home Street Address:
City: State: Zip:
Business Street Address:
City: State: Zip:
EDUCATION
Last School Attended:
Dates Attended: To:
Area of Specialization:
EMPLOYMENT (Two most recent employers)
Employer:
Position:
Dates: To:
Employer:
Position:
Dates: To:
BUSINESS AND PROFESSIONAL ORGANIZATIONS (Include Business Directorships)
Organization:
Position Held:
Dates: To:
Organization:
Position Held:
Dates: To:
Organization:
Position Held:
Dates: To:
CIVIC, CHARITABLE, OTHER ORGANIZATIONS
(Please list current or recent affiliations)
Organization:
Position Held:
Dates: To:
Organization:
Position Held:
Dates: To:
Organization:
Position Held:
Dates: To:
What do you feel are your strongest areas of expertise based on your background experiences?
| Medicaid |
| Fund Raising |
| Vocational Rehabilitation |
| Public Relations |
| Planning |
| Marketing |
| Government Relations |
| Special Education |
| Legal Affairs |
| Assistive Technology |
Other (specify):
Indiciate primary areas of interest outside your area of expertise:
| Medicaid |
| Fund Raising |
| Vocational Rehabilitation |
| Public Relations |
| Planning |
| Marketing |
| Government Relations |
| Special Education |
| Legal Affairs |
| Assistive Technology |
Other (specify):
The following information is optional:
Age: 20-35 36-50 51-65 Over 65
Ethnicity: Black White Asian Native American Hispanic
Other (specify):
Sex: Female Male
Please describe your disability:
I require the following accommodation(s) to participate in an interview (For example, interpreters, ASL, or language (please specify):
Accommodation:
If you have any questions regarding the application process, please contact Rebecca Cloutier at 401.462.7914.