Legal Name: *

Home Address Information

Home Address: *

Home City: *

Home State: *

Home Zip Code: *

Home E-mail Address:

Home Phone Number: *

Home Fax Number:

Cell Phone / Pager Number:

Business Address Information

Business Address:

Business City:

Business State:

Business Zip Code:

Business E-mail Address:

Business Phone Number:

Business Fax Number:

You Are (choose one of the following):*

Deaf
Hard of Hearing
Hearing
Speech-Impaired

Employment History
List employment with the most recent employer. Resume is optional.

Place of Employment:*

Position Title:*

Beginning Date Employed:* (month/year)

Ending Date Employed: * (month/year or present)

Education
List the schools attended.

High School Name: *

High School Location: * (city/state)

High School Dates Attended: * (year to year)

Did you graduate from high school? *

Yes No

College Attended:*
(enter the name of the college - if you did not attend college type none)

College Location: (city/state)

College Dates Attended: (year to year)

Did you graduate from college?*

Yes No

How did you become interested in the TRS Advisory Committee?*

How often do you use the Telephone Relay Service? *

The TRS Advisory Committee meets two to four times a year, on a weekday afternoon. Your term, if you are chosen will be for three years. Most of the meetings are in Lincoln. You will be reimbursed for mileage and parking expenses.

Are you able to commit to meetings for three years?*
Yes No

List any additional supportive information about yourself, experiences and background including why you would like to serve on this committee.