Immediate Call for Reviewers

REVIEWER CONTACT INFORMATION

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1. Name and Contact information
First Name:
Last Name:
Home Address:
Home Address 2:
Home City:
Home State:
Home Zipcode:
Home Phone:
Home Fax:
Home Email:
NOTE: You must supply a valid email address for either your Home email account or Work email (space provided below) or we may not be able to contact you.
Organization/Company:
Title (if applicable):
Work Address:
Work Address 2:
Work City:
Work State:
Work Zipcode:
Work Phone:
Work Fax:
Work Email:
Cell Phone:
Contact Preferences
Preferred Contact Method:	Phone Email Postal Mail
Preferred Contact Location:	Work Home Either

REVIEWER INFORMATION AND EXPERTISE
Ethnicity:	Please Select One Hispanic / Latino Not Hispanic / Latino
Race: Please select one or more	American Indian or Alaska Native Asian Black or African American Native Hawaiin or Other Pacific Islander White None of the Above
Gender:	Please Select One Male female
Professional Affiliation:	Please Select One Community Based Organization Consultant Faith Based Organization Government Research Service Delivery University Other
Other Affiliation: (please specify only if not found above)
Level 1 General Expertise. Please select the one area that best describes your general expertise.
Please Select One Substance Abuse Prevention Substance Abuse Treatment Mental Health None of the Above
Level 2 Expertise. Please choose no more than 4 areas that describe your specific level of expertise.
State Systems Research / Evalulation Criminal Justice Faith-based & Community Approaches Program Planning / Management HIV/AIDS Adolescents Alcohol Fetal Alcohol Sydrome Crack / Cocaine Ecstasy Heroin Marijuana Methadone Treatment Methamphetamine OxyContin Co-occurring Substance Abuse & Mental Health Children's Mental Health Traumatic Stress Seriously Mental Ill Adults Violence Counseling Other
Other Expertise: (please specify only if not found above)
Grant Reviewing Experience
I am a/an: Please Select One Experienced SAMHSA Reviewer Experienced Federal Reviewer Experienced Non-Federal Reviewer Limited or No Review History Please describe your experience in grant reviewing, listed from most recent to least recent.  Please include dates, location, ageny and topic:
REMINDER!
Resumes should be emailed to reviewer@samhsa.hhs.gov. NOTE: This form does not email your resume. You must do that separately, after you've finished filling out this form. If you are finished, please click SEND to submit your application. Thank you.