Gubernatorial Appointment Form

WEST VIRGINIA
COMMISSION FOR THE DEAF AND HARD-OF-HEARING
Nomination for Gubernatorial Appointment

Name:

SS#:

Address:

City:

State:

Zip:

County:

E-mail:

Day Phone:

Evening Phone:

Fax:

Date of Birth:

Sex:

Race:

I am interested in serving on the Commission Board because:

My experiences and qualifications include: (Please attach resume' if available):

I have the following personal and/or professional experiences regarding the problems and needs of people who are deaf or hard of hearing::

The purpose of the West Virginia Commission for the Deaf and Hard-of-Hearing Statewide includes the following:

Maintain a clearinghouse of information to assist with obtaining ap propriate services or information about such services;

Develop an outreach program to familiarize the public with the rights and need of persons who are deaf or hard of hearing;

Collect and maintain a register of persons who are dear or hard of hearing ;

Conduct and maintain a census of deaf and hard of hearing persons in West Virginia; and

Establish, maintain and coordinate a state wide service to provide a list of qualified and certified interpreters for the deaf; and a list of qualified and certified teacher of American Sign Language.

Members of the Board are appointed by the Governor. The Board composition must be comprised of at least three persons who are deaf or hard of hearing; a parent of a deaf child; a certified teacher of the deaf and hard of hearing; an audiologist; and an otolaryngologist. Applicants are requested to disclose the following information. Please check all that apply.

I am person who is deaf or hard of hearing

I am a parent or a guardian of a child who is deaf

I am a certified teacher of the deaf and hard of hearing

I am an audiologist

I am an otolaryngologist
Other

Three people who would recommend me for a position on the Board are:

Name:	Address:	Daytime Phone:

Name:	Address:	Daytime Phone:

Name:	Address:	Daytime Phone:

Questions regarding the Board or the application process may be directed to:
	Deanna Stone, Executive Director" WVCDHH Building 6, Room 863 Capitol Complex Charleston, WV 25306 (304) 558-1675 (Voice or TDD) FAX (304) 558-0937