Edmund G. Brown Jr.,
 Governor 

State of California
Health and Human Services Agency	
Orientation Center for the Blind Trust Fund Committee
Membership Application	
	
Thank you for your interest in serving on the Department of Rehabilitation’s Orientation Center for the Blind (OCB) Trust Fund Committee.  Please include your resume with your application.  

Eligibility for this Committee is restricted to graduates of the OCB.

All applications should be received no later than 07/05/2013.

Name, (First, Middle, Last): 

Address: 

City, State, Zip Code: 

Phone Number, including area code: 

Fax Number, including area code: 

Email Address: 

Business Title: 

Company/Employer: 

Company/Employer Address: 

Company/Employer City, State, Zip Code: 

Company Phone, including area code: 

Company Fax, including area code: 

Company Email: 

Please answer the following questions.  When appropriate, place an “x” in front of the appropriate choice.

Are you a graduate of the Orientation Center for the Blind?
	_____ Yes
	_____ No

If so, what date did you graduate?
	_____ (Month/Year)

I am applying to serve as a representative of (select one):
	_____ California Council of the Blind (appointments are made in consultation with the organization’s President)
	_____ National Federation of the Blind of California (appointments are made in consultation with the organization’s President)
	_____ Other Advocacy Group (specify group:_____________)
	_____ At-large Member

How do you describe yourself (select one)?
	_____ Blind 
	_____ Visually Impaired
	_____ Other (specify:______________) 

Which medium of communication do you prefer?
	_____ Braille 
	_____ Large Print 
	_____ Electronic 
	_____ Other (specify:_______________)

Please provide a brief statement of qualifications to address your potential contribution to the OCB Trust Fund Committee for the determination of the allocation of gifts, bequests, and donations to the OCB, by answering the following three questions.  You may attach additional sheets as necessary.

1)	Please explain your leadership capacity and experience in various group settings and/or how your participation will connect to a larger community of people/organizations with interest in advancing services and employment opportunities for students at the OCB.

2)	Briefly describe the interests you will represent and what you hope to contribute as a result of participating on the OCB Trust Fund Committee.

3)	From your current perspective, please summarize 2-3 desired outcomes of the OCB Trust Fund Committee.

SIGNATURE:__________________________________	DATE: ______________
Please send an electronic copy of your application and resume to Brian Connors, Advisory Committee Analyst, via e-mail at brian.connors@dor.ca.gov.  For any questions, contact Brian at (916) 558-5380.

Please also submit signed application with resume to:

Department of Rehabilitation
Attn: Brian Connors
721 Capitol Mall 
Sacramento CA 95814

Fax: (916) 442-0890