SRC Membership Application

Identification Data

Name
Home Address
Home Address
Business Address
Business Address

Education

Employment (2 most recent employers)

Employer #1
Employer #2

Business and Professional Organizations (Include Business Directorships)

Organization #1
Organization #2
Organization #3

Civic, Charitable, Other Organizations (Please list current or recent affilitations)

Organization #1
Organization #2
Organization #3
Select
What do you feel are your strongest areas of expertise based on your background experiences?
Select
Indicate primary areas of interest outside your area of expertise

The following information is optional

Age
Ethnicity
Sex

This information will be forwarded via email to the State Rehabilitation Council, and will be reviewed by the council for membership consideration.  If you do not want your information forwarded via email, please Do Not Submit, and instead print and mail in your application directly to Nancy Baker, PO Box 724, Wakefield, Rhode Island 02880.


If you have any questions regarding the application process, please contact Nancy Baker at risrc@cox.net.

Thank you for your application. You will be hearing from a member of the State Rehabilitation Council soon.
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