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Application For Advisory Committee Membership - Texas Health And Human Services Commission Page 4

Do you believe you will be able to regularly participate in Behavioral Health Advisory

Committee activities, if you are appointed? ?

Yes

If no, please explain:

Miscellaneous Information

Do you have a personal or private interest in a matter pending before HHSC? ("Personal or

private interest" means you have a direct monetary interest in the matter or owe your loyalty to

an entity involved, but does not include the member's engagement in a profession, trade, or

occupation when the member's interest is the same as all others similarly engaged in the

profession, trade, or occupation.)

Yes

References

Please provide the names and contact information for two people who can tell us more about

your qualifications to serve on the advisory committee. References can include employers,

clients, religious leaders, community leaders, advocates, friends, or others who know about your

interest in and/or involvement with service delivery through Medicaid. If you are applying as a

provider, include at least one client reference.

Reference #1

Name:

Address:

City:

State:

Zip:

Daytime Phone:

Email:

Relationship (how this person knows you):

Reference #2