Advisory Council on Aging

APPLICATION FOR MEMBERSHIP
For Member-at-large seats. (For city/local committee and designated organization seats, please contact those organizations for an application.)

PLEASE PRINT

1. NAME _____________________________________________________

2. HOME PHONE (_____)_____-__________

3. E-MAIL ___________________________

4. HOME ADDRESS _____________________________________________

______________________________________________________________

5. MAILING ADDRESS (if different) ____________________________________

______________________________________________________________

6. BUSINESS ADDRESS_________________________________________

______________________________________________________________

7. BUSINESS PHONE (_____) _____-_________________________________

8. CURRENT/FORMER OCCUPATION___________________________________

9. EDUCATION/BACKGROUND _______________________________________

10. COMMUNITY INVOLVEMENT/ACTIVITIES (Feel free to use the back of this sheet)

______________________________________________________________________

11. SPECIAL INTERESTS (Feel free to use the back of this sheet)

______________________________________________________________________

12. COMMITTEES AND WORK GROUP/S ON WHICH YOU WOULD BE INTERESTED IN SERVING: PLEASE REFER TO COMMITTEE AND WORK GROUP DESCRIPTIONS. (Council members must serve on at least one of our committees or work groups.)

______________________________________________________________________

Date _____________ Signature _____________________________________

Age: 60 or over _____ Under 60 _____

Please note: Members are required to file a conflict-of-interest form.

FAX COMPLETED FORM TO:
Area Agency on Aging (925) 335-8820

MAIL TO:
Area Agency on Aging
2530 Arnold Drive, Suite 300
Martinez, CA 94553

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