Loan Committee Application

Please attache your RESUME

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Name

First Name

Last Name

Email

Phone (Mobile):

Phone (Other):

Address

Address Line 1

Address Line 2

City

State

ZIP Code

1. Please tell us a little more about yourself.

Individual with a disability Family member, guardian or authorized representative of a person with a disability Representative of education Representative of employement Representative of health, allied health and rehabilitation Representative of financial services Representative of assistive technology

Other:

2. Gender

3. Age:

19 to 35 36 to 55 56 and Over

4. Race/Ethnicity:

American Indian/Alaska Native Asian Black/African American Hispanic/Latino Native Hawaiian and other Pacific Islander White/Caucasian

Other:

Please provide any other additional information you wish to share about your interest and commitment in being a member of the Loan Review Committee.

Please indicate your preference for Loan Committee meeting:

Monday: 5:00pm to 6:00pm Thursday: 12:00pm to 1:00pm

NDI Alternative Finance Project Loan Committee Application: