Board Application Company Applicant Title Choose One Mr. Ms. Mrs. Prof. Dr. First Name * Last Name * Email Address * Contact Number * Alternate Contact Number Address Address Address 2 City/Town State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Upload CV Add File Please upload your CV in PDF format. Current Employer Current Employer Address Address 2 City/Town State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Reference Reference * Address Address 2 City/Town State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Additional Information Membership Categories * Individual with disabilities that use assistive technology Family Member/ Legal Guardian of individuals with disabilities that use assistive technology A representative of a consumer Organization concerned with assistive technology A representative of business or industry, including the insurance industry, concerned with assistive technology State Agency Representative Membership is only available to individuals that represent one of these categories. Please select only one. Employment * Yes, My employer will allow me the flexibility to attend face-to-face meetings as well as teleconferences and webinars. No, My employer will NOT allow me the flexibility to attend face-to-face meetings as well as teleconferences and webinars. Skills you bring to FAAST Strategic Planning Financial Management Marketing Information Technology Human Resources Grant Writing Case Management Accounting Media Contacts Administration Fundraising Public Relations Assistive Technology Trainings Legal Issues Service Delivery Mediation Political Contacts Contacts with Professional Service Organizations Why do you want to be a member of the FAAST Board? * Describe your experience with assistive technology devices or services and your role. * Please list any other Boards, commissions, committees, and/or organizations you currently serve in or have served in the past. * Committees you would like to be a part of Technology and Public Awareness Public Policy and Advocacy & Interagency New Horizon Loan Program Service Delivery Development Message / Comments Information Summary
