APPLICATION FOR ENDORSEMENT TO THE GOVERNOR FOR APPOINTMENT TO THE NORTH CAROLINA COUNCIL ON DEVELOPMENTAL DISABILITIES (Please type or print legibly.) NAME: First Middle Last ________________________________________________________________________________ ADDRESS:________________________________________________________________________ TELEPHONE: HOME ( ) BUSINESS ( ) FAX ( ) EMAIL ______________________ BACKGROUND INFORMATION This endorsement is for the following category: ¥ An individual with developmental disabilities/self-advocates (see definition attached). ¥ A parent or guardian of a child (0-21) with developmental disabilities; ¥ An immediate relative or guardian of an adult with cognitive developmental disabilities who cannot advocate for himself/herself, including an individual with a developmental disability who resides or previously resided in an institution. ¥ A representative of a local and non-governmental agency, and private nonprofit group concerned with services to persons with developmental disabilities. If parent or guardian of a child with a developmental disability, please provide child's age: Please tell us about yourself/the candidate. Briefly discuss how you/the candidate became interested in disability issues, and present or past involvement in disability advocacy. DEMOGRAPHIC INFORMATION: (optional) DATE OF BIRTH: SEX: Male Female ETHNIC GROUP: (This information is helpful in endorsing applicants of culturally diverse backgrounds.) _ White _ Black (African-American) _ Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, other) _ Asian (including Pacific Islander) _ American Indian (including Alaskan native) _ Other (optional specify) I WANT TO BE CONSIDERED FOR ENDORSEMENT TO THE NC COUNCIL ON DEVELOPMENTAL DISABILITIES BECAUSE: (What skills and interests would you bring to the Council?) (Please keep to 1 page) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ POSITION QUESTIONS (Please give brief answers.) 1. What do you believe are the two or three most important issues for people with developmental disabilities and their families? Please explain. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2. What activities should an organization such as the Council undertake to address these issues? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Please return this application and other requested material--(rŽsumŽ, vita, or personal/family history, optional) and letters of recommendation--by ______________ on line at the Council web site http://www.nc-ddc.org/, or to the following address: John McCallum, Assistant Director of Quality Management NC Council on Developmental Disabilities 3801 Lake Boone Trail, Suite 250 Raleigh, NC 27607 (Voice/TDD) (919)420-7901 (Toll Free) (800)357-6916 (FAX) (919)420-7917