M110 OAC Application Form 2025-29

M110 OAC Application Form 2025-29

This application form is to apply for a membership on the Oversight & Accountability Council (OAC) for a term of 4 years. The OAC is responsible for approving funding for Behavioral Health Resource Networks (BHRNs) and increase access to community care. A BHRN is an entity or collection of entities that individually or jointly provide substance use related services.

The Members of the OAC shall be qualified individuals with experience in substance use treatment and other addiction services.

For additional information please see Oregon Revised Statutes (ORS) 430.383 to 430.394.

Last Name*

First Name*

Address 1

Street or PO Box

Address 2

Suite, Apartment #, Room #

City

State (2 letter state)

Select or enter value

Zip Code

County

Select or enter value

Email Address

Phone Number*

Phone

Member Seat Applying for*

Multiple selections can be made.

Select

Why are you applying for OAC membership?*

Describe your relevant background & experience*

What other Boards or Committees are you on?

Please list boards that you are currently serving on or have served on in the past.

Define equity/inclusion in your own words.*

Attestation of time expectation: Est. 15 hrs/month*

Meetings are regularly held the 2nd and 4th Wednesday of each month from 1:30 to 3:30 p.m. It is possible that additional meetings may be required to complete Council business. This is a 4-year term. Please attest that you can meet this obligation.

Select or enter value

Please feel free to upload a resume, letter of support, or other supporting documentation

Drag and drop files here or

Alternative Format

This document can be provided upon request in an alternate format for individuals with disabilities or in a language other than English for people with limited English skills. To request this document in another format or language, contact Karli Cunningham at (971) 240-8690 or Kathy Cervantes at (503) 784-3737, 7-1-1 for TTY, or email OHA.Measure110@oha.oregon.gov.

If possible, please list what you need below.

Send me a copy of my responses

Privacy Notice|Report Abuse