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APPLICATION FOR NOMINATION
LOUISIANA REHABILITATION COUNCIL

Louisiana Rehabilitation Services (LRS) as authorized under the Rehabilitation Act of 1973
(P.L. 93-112) as amended, is seeking nominees to be considered for appointments on the
Louisiana Rehabilitation Council.

If you are interested in serving on the Council, please provide the following information:


(*) Entry Required





  2. Character Count: (Max 300, remaining 300.)


  3.  (Layout to enter: xxxxxxxxxx)   



I. * Council members are sought in the following categories.
        Please indicate the appropriate category that applies to you.
        If you are eligible for more than one category, indicate first (1st) choice,
             second (2nd) choice, etc.
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     I am a member of the Statewide Independent Living Council.
     I am a representative of a Parent Training and Information Center.
     I am a representative of the Client Assistance Program (CAP).
     I am a representative for Community Rehabilitation Program service providers.
     I am a representative of the business, industry, or labor sector.
     I am an adult with a disability.
     I am a:

 Parent       Family Member       Guardian
 Advocate of an individual(s) with disabilities who has(have)
     difficulty representing themselves.

     I am a current applicant or recipient of Vocational Rehabilitation services.
     I am a former applicant or recipient of Vocational Rehabilitation services.
     I am a representative of the State Department of Education.
     I am a member of the State Workforce Investment Board.
     I am a representative of the Title 121 (Tribal) Program.
     I am a Vocational Rehabilitation Counselor.

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II. * Brief Biographical Sketch:

Character Count: (Max 640, remaining 640.)

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III. * Describe your direct experience and/or activities related to the field of disabilities:

Character Count: (Max 640, remaining 640.)

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IV. * Explain why you think your experience/activities would be an asset to the Council:

Character Count: (Max 640, remaining 640.)

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V. * Indicate the frequency you could devote to Council activities:
       one day/week       one day/quarter
       one day/month     other (specify):

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VI. Additional Information (optional):
     Disability: Yes    No    Specify Disability:
     Parish of Residence:
     I am a(n): Individual with a disability   Family Member   Rehab Counselor
                      Educator    Advocate    Service Provider
                      Other

By submission of this form I would like to be considered for appointments on
the Louisiana Rehabilitation Council.

If you have any other questions, please email CRyland@lwc.la.gov.

NOTE: Council members will be reimbursed for their travel expenses according to the State Travel Regulations.