Community Advisory Board Member Interest Form

Thank you for your interest in serving on the Community Advisory Board for the Detroit Health Department. Please complete the following form to help us understand your background, experience, and interest in this role.

 

 

Personal Information

 
 
 
 
Phone
 
 
 
 
 
 
 
 

 

Interest and Availability

 
 
 
 

 

Additional Demographic Information

 
 
 
 

 

References

Please provide the name and contact information of two references (non-family members) who can speak about you

 
 
Phone
 
 
 
 
Phone
 
 
 

 

Conflicts of interests and transparency:

 
 
 
 
 

Signature

By signing below, I confirm that the information provided is accurate and that I am interested in being considered for a position on the Community Advisory Board.

 

By typing my name below, I understand and agree that this form of electronic signature has the same force and effect as a manual signature.

 
 
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