VT AT Advisory Council Application

Thank you for your interest in joining the VT AT Program Advisory Council. Finalists will be reviewed by the Director of the AT Council and considered by council members. You may be asked for additional information or an interview.

If you would like support filling out this application or have questions, please contact the VT AT Program at 1-800-750-6355 or email dail.atinfo@vermont.gov

First Name

Last Name

Physical Address

Mailing Address

Phone Number

Membership Category

User of AT, with a disability

Parent or Family member of an AT User with a disability

Business or Agency Representative; if you select this Category please select a Representative Type.

Representative Type

Representative of Voc Rehab

Representative of VBVI

Representative of VCIL

Representative of Workforce Investment Board

Representative of Agency of Education

School Representative

What is your preferred delivery method for meeting materials and agendas?

Have you ever been elected or appointed to Public Office in VT?

Are there any accommodations you would like to request while attending VT AT Council Meetings?

Please describe why you would like to be on the Council?

Can you attend four meetings per year?

Reference 1: First and Last Name

Reference 1: Phone Number

Reference 1: Email Address

Reference 1: How do you know each other?

Reference 2: First and Last Name

Reference 2: Phone Number

Reference 2: Email Address

Reference 2: How do you know each other?

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