SRC Membership Application Identification Data Name First Last Work Phone Cell Phone Email Home Address Home Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Business Address Business Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Education Last School Attended Dates Attended To Area of Specialization Employment (2 most recent employers) Employer #1 Employer Position Dates To Employer #2 Employer Position Dates To Business and Professional Organizations (Include Business Directorships) Organization #1 Organization Position Held Dates To Organization #2 Organization Position Held Dates To Organization #3 Organization Position Held Dates To Civic, Charitable, Other Organizations (Please list current or recent affilitations) Organization #1 Organization Position Held To Dates Organization #2 Organization Position Held Dates To Organization #3 Organization Position Held Dates To Select 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 Eduction Legal Affairs Assistive Technology Other Other (Specify) Select Indicate primary areas of interest outside your area of expertise Medicaid Fund Raising Vocational Rehabilitation Public Relations Planning Marketing Government Relations Special Eduction Legal Affairs Assistive Technology Other Other (Specify) The following information is optional Age 20-35 36-50 51-65 Over 65 Ethnicity Black White Asian Native American Hispanic 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) Accomodation 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. CAPTCHA What code is in the image? Enter the characters shown in the image. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank