First and Last Name:

Date of Birth:

Email Address:

Phone Number:

Address: (Street, City, State, Zip Code)

Do you work for or serve on a board of an agency that receives Older American Act Title III funding? Do you work for or serve on a board of an agency that receives Older American Act Title III funding? Yes No

Describe your qualifications to be on the Advisory Committee:

Describe your employment experience:

Describe your civic, community or volunteer activities:

What can you contribute to the Advisory Committee on Aging?

To meet reporting requirements for the Minnesota Board on Aging, we ask Advisory Committee on Aging members to provide the following information. This is optional—if you prefer not to share, simply leave the question blank.

Are you an elected official currently holding public office? Are you an elected official currently holding public office? Yes No

If yes, please list title and term of office:

Are you a representative of a health care provider organization, including providers of veterans’ health care? Are you a representative of a health care provider organization, including providers of veterans’ health care? Yes No Prefer not to answer

Do you work for or serve on the board of an agency (i.e. legal assistance, nutrition, evidence-based disease prevention and health promotion, caregiver, long-term care ombudsman, and other service provider)? Do you work for or serve on the board of an agency (i.e. legal assistance, nutrition, evidence-based disease prevention and health promotion, caregiver, long-term care ombudsman, and other service provider)? Yes No

Do you have leadership experience in the private sector? Do you have leadership experience in the private sector? Yes No Prefer not to answer

Do you have leadership experience in the voluntary (nonprofit or community) sector? Do you have leadership experience in the voluntary (nonprofit or community) sector? Yes No Prefer not to answer

Do you identify as: Do you identify as: American Indian or Alaska Native Black or African American White Asian or Asian American Native Hawaiian or Pacific Islander Other Prefer not to answer

Do you identify as: Do you identify as: Hispanic or Latino Non-Hispanic Prefer not to answer

Do you identify as an individual in greatest economic need as identified through the Older Americans Act? Do you identify as an individual in greatest economic need as identified through the Older Americans Act? Yes No Unknown Prefer not to answer

Do you identify as an individual in greatest social need as identified through the Older Americans Act? Do you identify as an individual in greatest social need as identified through the Older Americans Act? Yes No Unknown Prefer not to answer

Are you a family caregiver? Are you a family caregiver? Yes No Prefer not to answer

Are you an older relative caregiver of children or adults aged 18 to 59 with a disability? Are you an older relative caregiver of children or adults aged 18 to 59 with a disability? Yes No Prefer not to answer