Please complete this form to be considered for inclusion in the Resource Persons Network. This information will be sent to the RPN Manager via email for review and you will be contacted for any questions that may arise. Required fields are marked with an asterisk (*).

*	Name
	Title/Position
*	Mailing Address
*	Work Phone
	Home Phone
	Fax Number
*	E-mail
	Race/Ethnicity	Prefer not to disclose American Indian/ Alaska Native Asian American Black / African American Hispanic Latino Native Hawiian / Other Pacific Islander Other - Please specify below White - non-Hispanic   OR
	Language Proficiency	Cambodian Chinese English Gujarati Hindi Japanese Korean Samoan Spanish Tagalog Thai Vietnamese
	Education and Training(Degree, School, Year)
	Method of Service Delivery	E-mailPhoneSite Visit
Experience with specific populations
	Black/African American (Please describe briefly)	Haitian African (Specify) Caribbean Basin (Specify)
	Hispanic / Latino (Please describe briefly)	Cuban American Mexican American Puerto Rican Central American (Specify) South American (Specify) Other Hispanic/Latino (Specify)
	Asian American (Please describe briefly)	Filipino Korean Vietnamese Chinese (Specify) Other Asian (Specify)
	Native Hawaiian/Other Pacific Islanders (Please describe briefly)	American Samoa Native Hawaiian Other Pacific Islander (Specify)
	American Indian / Alaska Native (Please describe briefly)	American Indian (Specify) Alaska Native (Specify)
	Attach Resume (MS Word only)