PAN Assistant State Director Application Form

 
     

    I.   CONTACT INFORMATION

  •  
  •  
  •  
  •  
  • Email   Phone
  •  
     

    II.   PERSONAL INFORMATION

  •  
  •  
  •  
  •  
  •  
  • Yes No
  • If yes, enter any related pertinent information below:
  •  
  •  
     

    III.   POSITION INFORMATION

  • Yes No
  •  
  •  
  •  
  •  
  •       Develop a relationship with your Representative and his/her staff?
  •       Complete PAN Action Alerts
  •       Communicate regularly with your State Director?
  •       Speak at support groups?
  •       Locate new support groups to speak to?
  •       Engage local print media (letters to the editor, op-eds)?
  •       Engage local television/radio?
  •       Use social media?
  •       Host tables at community events?
  •      
  •  
  • Yes   No   Unsure
  •  
  •  


 
 
Please contact PAN at advocate@parkinsonsaction.org
if you're having difficulty with this form.