NTGA Planning Council Application Form

Nashville TGA Planning Council

Application for Membership

To help us process your membership application, please provide all of the information requested. Enter

N/A

(not applicable) where appropriate. Please type or print clearly. If you need assistance filling out thisapplication, please contact the planning council support office at

615-340-56

2

3

. Before completing yourform you may wish to read the overview of the Planning Council on pages 8 & 9.Please

email or

mail your completed application to:

Trevor Henderson.Ryan White Program,311 23

rd

Avenue North,Nashville, TN, 37203

Page 1 & 2 of this form are considered public record. All other pages and their content areconsidered confidential. All other pages are only seen by the Planning Council Support staff,and as needed, by members of the Membership Committee and/or the Executive Committeeduring the member’s selection process. Part 1: Contact Information

Name_________________________________________________________________________HomeAddress___________________________________________________________________City_______________________________________ State__________ Zip Code_____________Home Phone Number_____________________ Alternate Phone Number___________________I am a resident of which County:



Cannon



Cheatham



Davidson



Dickson



Hickman



Macon



Robertson



Rutherford



Smith



Sumner



Trousdale



Williamson



Wilson



OtherEmail Address ________________________________________________________________

Preferred way to be contacted between 8.00am and 4.30pm?



Home Phone



Alternate Phone



EmailMay we add you to our email list?



Yes



No

Draft Copy Oct. 2007

1

I have read the

Statement of Member Commitment

,

Conflict of Interest Statement

and the

Terms of Participation

and fully understand them. I hereby agree to fulfill my duties as a Planning CouncilMember as explained therein.

Signature:__________________________________________________ Date: ______ / _______ /

___________

Print Form

Nashville TGA Planning Council

Application for Membership

Biography

Please provide us with a brief description of yourself, your experience, education and in what ways youfeel that you can contribute something to this program.Name

:____________________________________________________________________________

Current Job/Position:

___________________________________________________________________

Educational background/If any

(starting with most recent)

:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Professional/Volunteer/Work Experience/ If any

(starting with most recent)

:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What skills or knowledge do you feel you can bring to the Planning Council?:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What experience do you have with the HIV/AIDS community?:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________

Draft Copy Oct. 2007

2

Nashville TGA Planning Council

Application for Membership

Part 3: Personal Information

For the questions below, please check for each category with which you most easily identify. Feelfree to include any additional information that you use to describe yourself on the ‘other’ linesprovided. Your responses will be kept

CONFIDENTIAL

and will only be available to PlanningCouncil Support staff, and as needed, by members of the Membership Committee and/or theExecutive Committee during the member’s selection process.

A.

I am



Male



Female



Transgender



Other _________________

B.

My age range is