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2. First Name
3. Last Name
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Email Address
14. County of Residence*
    -- Select One --FerryPend OreilleStevensOther
15. Other County of Residence

    If you selected "other" as your county of residence please provide the county you reside in. 

17. 1) Do you have expertise/experience in any of the following areas? *

    1. Health care access and quality
    2. Physical environment, including built and natural environments
    3. Social and economic sectors including housing, basic needs, education, and employment
    4. Business and philanthropy
    5. Communities that experience health inequities
    6. Government
    7. Tribal communities and tribal government
    8. None-I have no experience/expertise in the above areas
19. 2) What category best describes your experience in areas impacting public health? *

    1. Member with expertise/experience in any of the areas listed in question 1
    2. Consumer of public health services
    3. Community members with lived experiences in areas listed in question 1
    4. Community stakeholders, including nonprofit organizations, the business community, and those regulated by public health
21. Summary of Interest*

    Please provide a brief summary of your interest in serving on the Public Health Advisory Board. 

23. Relevant Documents

    Optional: Upload documents relevant to your experiences/expertise.

24. Relevant Documents

    Optional: Upload documents relevant to your experiences/expertise. 

Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field