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* 1. Name

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* 2. Address

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* 3. Phone number (including area code)

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* 4. E-mail address

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* 5. Gender identity (optional) - you may choose more than one:

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* 6. Racial / Ethnic background

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* 7. Occupation

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* 8. Nomination by

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* 9. Membership Category – Please list the open membership category (or categories) for which you are applying. You may view the list of open positions on the committee website.

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* 10. Please provide a brief statement of qualifications that highlights the relevant skills and experience you would bring to the Alzheimer's Advisory Committee.

In addition, please answer these questions:

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* 11. Briefly describe the interests you will represent and what you hope to contribute as a result of participating on the Alzheimer's Advisory Committee.

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* 12. What are the central issues related to Alzheimer’s and other dementias you would recommend the committee consider and why?

*Please note the committee meets quarterly, usually on the first Thursday of each month in February, May, August, and November. Upcoming meeting dates are posted on the committee website.

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* 13. Signature of the person completing this form.
**Typing in your full name below is considered equivalent to a signature.

Click done to submit your application.

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