Name
Home Address
Mailing Address
Telephone Home work
Email Address
Gender Male Female
Age
Race
Employed By
Date

Please indicate all areas that apply: 
1. Professional representative from the fields of psychology.
social work   nursing religion business
or Other
2. A primary consumer
family member an individual interested in individuals with substance abuse issues. Other
3. Expertise in Finance
Management Information Systems or other (please specify)
 
4. Professional Activities
5. Volunteer Activities
6. Why do you wish to serve on the Board of Directors of East Coast Solutions?
7. What areas of concern would you like to see the Board address?
8. What do you feel are your qualifications for serving on the Board?
Signature: