Application for Endorsement to the Governor for Appointment to the North Carolina Council on Developmental Disabilities
APPLICANT NAME
First Name:
Middle Name:
Last Name:
ADDRESS
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
TELEPHONE
Home:
Business:
Fax:
E-mail:
BACKGROUND INFORMATION
This endorsement is for the following category:
An individual with developmental disabilities/self-advocate
(see definition)
A parent or guardian of child(ren), age 0-21, with developmental disabilities
An immediate relative or guardian of an adult with developmental
disabilities
An immediate relative or guardian of an adult with a developmental disability who
resides, or previously resided, in an institution; or an individual with a
developmental disability who resides, or previously resided, in an institution
Representative of a local and non-governmental agency, or private, not-for-profit
group concerned with services to persons with developmental disabilities
If parent or guardian of a child with a developmental disability,
please provide childs 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:
ETHNIC GROUP: (This information is helpful in endorsing applicants of culturally diverse backgrounds.)
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 submit this application and other requested material--(résumé, vita, or personal/family history, optional) and letters of recommendation by clicking the SUBMIT button below, or you can print this document and send to the following address:
John McCallum, Assistant Director for Quality Management
NC Council on Developmental Disabilities
3801 Lake Boone Trail, Suite 250
Raleigh, NC 27607
(Voice/TDD) (919) 420-7901
(Toll Free Voice/TDD) (800) 357-6916
(FAX) (919) 420-7917
When you submit an application online, please let us know you have sent it by emailing John McCallum at john.mccallum@nccdd.org.
Thank you!
