RICAT Application for Membership

If you would like to be considered as a member of RICAT,
please complete the following information:

IDENTIFICATION DATA

Name:

Work Phone: Home Phone:

Email:

Home Street Address:
City: State: Zip:

Business Street Address:
City: State: Zip:

EDUCATION

Last School Attended:
Dates Attended: to
Area of Specialization:

EMPLOYMENT

Two Most Recent Employers:

Firm:
Position:
Dates: to

Firm:
Position:
Dates: to

BUSINESS & PROFESSIONAL ORGANIZATIONS (include Business Directorships)
Please list current or recent affiliations:

Organization:
Office Held:
Dates: to

Organization:
Office Held:
Dates: to

Organization:
Office Held:
Dates: to

CIVIC, CHARITABLE, OTHER ORGANIZATIONS
Please lit current or recent affiliations:

Organization:
Office Held:
Dates: to

Organization:
Office Held:
Dates: to

Organization:
Office Held:
Dates: to

What do you feel are your strongest areas of expertise based on your background experiences?

Medicaid Fund Raising Vocational Rehabilitation Public Relations

Planning Marketing Government Relations Special Education

Legal Affairs Assistive Technology

Other (specify):

Indicate primary areas of interest outside your area of expertise:

Medicaid Fund Raising Vocational Rehabilitation Public Relations

Planning Marketing Government Relations Special Education

Legal Affairs Assistive Technology

Other (specify):

The following information is optional:

Age: 20-35 36-50 51-65 Over 65

Ethic: Black White Asian Native American Hispanic
Other (specify):

Sex: Male Female

Please describe your disability:

__ I require the following accommodation(s) to participate in an interview (For example, interpreters,
ASL, or language (please specify): ________________________________

Please fill out and print off this form and return to:
RICAT
C/O Office of Rehabilitation Services
40 Fountain Street
Providence, RI 02903

If you have any questions regarding the application process,
please call Sharon DiPinto at 401.421.7005 ext. 318.