AT Advisory Council

Nomination Form

Required fields are marked with an *.

Your Name:
Your Address:
Your City/Town:
Your Zip Code:
State:
Your e-mail address:	*If you supply an email you will receive a copy of your submission
Your Telephone Number:
Telephone Type:	Voice TTY
Best day/time to contact you:
Please tell us about your personal experience with assistive technology, whether for yourself or a family member:
Would you or a member of your family be available to attend Advisory Council meetings three or four times annually?	Yes No
We are looking for other individuals who could contribute to the Advisory Council. If you would like to nominate someone, please share their contact information with us:
COMPOSITION OF THE AT ADVISORY COUNCIL AS REQUIRED BY THE AT ACT OF 1998, AS AMENDED A majority, not less than 51%, of the members of the advisory council must be individuals with disabilities who use assistive technology or the family members or guardians of individuals with disabilities meeting these criteria.
Please select which – if any – of the following apply to you:
Members of the advisory council appointed as representatives of the entities described above shall not count toward the majority membership requirement. The advisory council should reflect the geographical diversity of the State with respect to race, gender, age, ethnicity, disabilities and users of types of services that an individual with disabilities may receive. Members of the advisory council shall receive no compensation for their service on the council but shall be reimbursed for reasonable and necessary expenses incurred in the performance of the official duties.

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