Membership Application / Nomination Form

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Home > Local Government > Mayor > Diversity > Mayor's Advisory Council on Disabilities > Membership > Membership Application / Nomination Form

MACD APPLICATION/NOMINATION FORM

If you would like to be considered for membership on the Mayor's Advisory Council on Disability (MACD) or nominate an individual, you can apply online. Simply provide the information requested below and then press SUBMIT. If you have any questions or comments about this form, you can send them to us through the "Feedback" link at the bottom of this page.

If you prefer, you may also request a hard copy of this form by calling 317/ 327-3798 or by mailing your request to:

Coordinator, Indianapolis Office of Disability Affairs
200 East Washington Street, Suite 2449
Indianapolis, IN 46204

The Executive Committee of the MACD will review each potential appointee in the late fall and then submit recommendations to the Mayor, who will determine final appointments.


Applicant/Nominee Personal Contact Information
Name
Street Address
City
State
Zip Code
E-mail
Phone Number

Applicant/Nominee Business Contact Information
Employer
Job Title
Street Address
City
State
Zip Code
E-mail
Phone Number
Fax

Nominating Party Contact Information
Name
Street Address
City
State
Zip Code
E-mail
Phone Number

Please describe the applicant/nominee's experience with disability issues:


Please list the special talents, skills, qualifications, and personal attributes the applicant or nominee will contribute to the MACD:


Why do you wish to apply for the MACD or to nominate this person for the MACD?


Is the applicant/nominee able to attend approximately 10 meetings per year and to be actively involved in subcommittee work?
Yes: No:

Please list any memberships or offices the applicant/nominee has held in professional, trade, or private organizations or clubs:


Does the applicant/nominee or any of his or her family members currently have a direct or indirect monetary interest in any contact with the City of Indianapolis or Marion County, other than a contract of employment?
Yes: No:

If yes, please explain:


	Last Updated: 12/31/2007