NM BORDER HEALTH COUNCIL

NEW MEMBER QUESTIONNAIRE

Membership is open to all interested individuals

Thank you for your interest in serving as a member of the New Mexico Border Health Council. The next meeting of the General Membership is scheduled for January 11, 2001.

Please complete the following questionnaire. Thank you.

Prefix (select one): Name:

Work Address:

Occupation/Title:

Agency/Business:

Home Address:

Home Phone: Bus. Phone:

Fax: E-mail address:

1. Please indicate your community service contributions:

Current:Previous:

2. Please comment on your health-related areas of interest:

3. What do you believe to be the most pressing health problems in your community?

4. Do you have an interest in serving on the Governing Board (Quarterly meetings):

5. Do you have an interest in serving on the Executive Committee (Monthly meetings):

6. Please indicate preferences for meetings:

Mon. Tues. Wed. Thurs. Fri. Sat.

a.m. and/or p.m.


Thank you. You may provide additional comments below:


New Mexico Border Health Office
District III, Public Health Division
1170 N. Solano, Ste. L
Las Cruces, NM 88001
Phone: (505) 528-5156
Fax: (505) 528-6045
Toll free: 1-800-784-0394
bho@nmsu.edu
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 New Mexico's motto is
Crescit Eundo    
(It Grows As It Goes)

Last Modified:
Monday, October 29, 2001