Application For Advisory Committee Membership - Texas Health And Human Services Commission Page 5
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5Relationship (how this person knows you):
Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)?
No
Yes
If yes, please explain:
All the information contained in this application is true and correct. I understand that the
advisory committee will meet in Austin, Texas at least four times per year. If selected, I
will make every effort to attend all advisory committee meetings.
Signature (typed name is acceptable)
Date
Please return this form and any supporting documentation to:
Email: BHAC@hhsc.state.tx.us
Attn: Karissa Sanchez
Mail: Texas Health and Human Services Commission
P.O. Box 13247, Mail Code 1155
Austin, Texas 78711
Attn: Karissa Sanchez
Fax: 512-424-6669
Attn: Karissa Garcia
If you have any questions about the application or the Behavioral Health Advisory Committee,
please contact Karissa Sanchez at 512-487-3337 or by email at
Karissa.sanchez@hhsc.state.tx.us.
HHSC is an equal opportunity employer and provider.
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