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Individuals who may apply: Any individual who reflects leadership, expertise, service and or advocacy pertinent to prevention, early intervention, treatment and recovery related to substance use disorders and co-occurring disorders is eligible to apply, which includes the following: Persons in recovery or those involved in prevention/early intervention/treatment/recovery of substance use disorders, particularly youth, elderly, minority, women, disabled and other at-risk populations; Knowledgeable professionals such as educators, researchers, etc.; Knowledgeable persons who have shown an interest and active involvement in the field of substance use and/or co-occurring disorders and addictions, including consumer advocates; Officials from law enforcement, local government, social services, youth services, mental health or co-occurring disorders services and other such areas impacted by substance use disorders; Representatives of the community including individuals with expertise in the social, criminal, medical and other effects of substance abuse and/or co-occurring disorders; and Individuals with expertise in substance abuse, mental health and/or co-occurring disorders. Current PAC members who submitted a letter of interest to remain on the PAC do not need to submit this application. Qualifications needed by an applicant to be considered: Applicants should have demonstrated competency in one or more of the following areas: Knowledge of ӣƵ behavioral health systems; Knowledge of substance use disorder prevention, early intervention, treatment and recovery support services; Knowledge of mental health services and systems; Improving quality of care; Medical linkage; Improving service efficiency; Improving outcome measurement; Increasing available resources; Workforce development; Needs assessment/data; Performance based contracting; Knowledge/experience with administrative service organizations; Integration with primary health care; Improving performance; Utilization management; and/or Improving co-occurring substance abuse/ mental health integration Location and meeting accommodations: Meetings will be held monthly on the third Friday from 10:00 a.m. to 12:00 p.m. at the Monmouth County Human Services Building, located at 3000 Kosloski Road in Freehold, ӣƵ, first floor conference room. Procedure to apply: Eligible and interested individuals may obtain an application from the Department of Human Services website at  HYPERLINK "http://www.state.nj.us/humanservices/providers/grants/public/" http://www.state.nj.us/humanservices/providers/grants/public/ Interested individuals may also contact Alicia Meyer at 609-777-0069 or by e-mail at  HYPERLINK "mailto:alicia.meyer@dhs.state.nj.us" alicia.meyer@dhs.state.nj.us. Applications must be submitted to: One original signed application and 5 copies must be submitted to: Alicia Meyer Division of Mental Health and Addiction Services ӣƵ Department of Human Services P.O. Box 700 Trenton, NJ 08625 - 0700 For UPS, Fed Ex or hand delivery, please alter address to read: 222 South Warren Street 3rd floor Trenton, NJ 08611 Faxed or emailed applications will not be accepted. You will NOT be notified that your package has been received. If you require a phone number for delivery, you may use (609) 633-2243. Deadline by which all applications must be submitted: Applications (including licenses/credentials and resumes) must be postmarked by September 7, 2016. Date by which applicants will be notified: Applicants will be notified on or before November 1, 2016. Professional Advisory Committee Application Division of Mental Health and Addiction Services ӣƵ Department of Human Services Please complete and return an original and 5 copies to Alicia Meyer by September 7, 2016. Be sure to include copies of all credentials/licenses and your resume in your original application and 5 copies. Attach additional sheets as needed. Name:  FORMTEXT       Home Address:  FORMTEXT       Daytime Telephone Number:  FORMTEXT       Cell Phone Number:  FORMTEXT       Email Address:  FORMTEXT       Name and Address of Employer:  FORMTEXT       List all professional licenses and certifications:  FORMTEXT       Provide a description of how you demonstrate leadership, expertise, service and/or advocacy pertinent to substance use disorders and addictions.  FORMTEXT       What changes would you like to see implemented to improve prevention, early intervention, treatment and recovery support services in New Jersey?  FORMTEXT       Provide evidence of how your experience and qualifications demonstrate one or more of the following areas: Knowledge of New Jersey behavioral health systems; Knowledge of prevention, early intervention, treatment and recovery support services; Improving quality of care; Medical linkage; Improving service efficiency; Improving outcome measurement; Increasing available resources; Workforce development; Needs assessment/data; Performance based contracting; Knowledge/experience with administrative service organizations; Integration with primary health care; Improving performance; Utilization management; and/or Improving co-occurring mental health/substance abuse integration.  FORMTEXT       What do you consider to be your area of expertise?  FORMTEXT       Why do you think you will be a good PAC Member?  FORMTEXT       Region of Residence:  FORMCHECKBOX  North  FORMCHECKBOX  Central  FORMCHECKBOX  South Have you ever been disciplined or denied a professional license or certificate of any kind in ӣƵ, any other state, the District of Columbia or in any other jurisdiction?  FORMCHECKBOX Yes  FORMCHECKBOX No Have you ever had a professional license or certificate of any type suspended, revoked or surrendered in ӣƵ, any other state, the District of Columbia or in any other jurisdiction?  FORMCHECKBOX Yes  FORMCHECKBOX No Has any action (including the assessment of fines or other penalties) ever been taken against your professional practice by any agency or certification board in ӣƵ, any other state, the District of Columbia or in any other jurisdiction?  FORMCHECKBOX Yes  FORMCHECKBOX No Have you ever been named as a defendant in any litigation related to the practice of alcohol and drug counseling or other professional practice in ӣƵ, any other state, the District of Columbia or in any other jurisdiction?  FORMCHECKBOX Yes  FORMCHECKBOX No Are you aware of any investigation pending against a professional license or certificate issued to you by a professional board in ӣƵ, any other state, the District of Columbia or in any other jurisdiction?  FORMCHECKBOX Yes  FORMCHECKBOX No Are there any criminal charges now pending against you in ӣƵ, any other state, the District of Columbia or in any other jurisdiction?  FORMCHECKBOX Yes  FORMCHECKBOX No 2=\]}~rh^QG^:G:^:h)h0BOJQJ^Jh 6OJQJ^Jh.h.OJQJ^Jh.OJQJ^Jh],OJQJ^Jh)h1=0OJQJ^Jh)h1=05OJQJ\^Jh)h5OJQJ\^J#h)h55CJ OJQJ^JaJ h55CJ OJQJ^JaJ h1=05CJ OJQJ^JaJ #h)h)5CJ OJQJ^JaJ h15CJ OJQJ^JaJ h 65CJ OJQJ^JaJ 2]~  8 9  H h9:t & F hhh^h`hgd.gdb@$ & F h0^`0a$gdiF;$a$gdiF;gd.gd?$a$gd)   " # C F G X Y Z n o r  ! $     + 5 Ȼ鱧ջߓyiYh)h1=05OJQJ\^Jh)h,d5OJQJ\^Jh)h5OJQJ\^JhY'OJQJ^Jh1OJQJ^Jh 6OJQJ^Jh_OJQJ^JhbOJQJ^Jh)h,dOJQJ^Jh)h)OJQJ^Jh2iOJQJ^Jh1OJQJ^Jh.OJQJ^Jh)h{?:OJQJ^J5 7 8   . m   # 2 3 ? G =KL~ܻܮššŮš}Żšsh OJQJ^Jh)hgpOJQJ^Jh)h|EOJQJ^Jh1OJQJ^Jh)h(VOJQJ^Jh)h zOJQJ^JhY'OJQJ^JhgpOJQJ^Jh)hT_FOJQJ^Jh)hfOJQJ^Jh],OJQJ^Jh)h1=0OJQJ^J+EYgh 789:stwgZL|OJQJ^Jh1OJQJ^Jh-QOJQJ^JhCOJQJ^Jh)h-QOJQJ^JhgpOJQJ^J@B]`abwx34qrsu˻}k}X}J9!h)h1=0B*OJQJ^Jphh_B*OJQJ^Jph$h~h_0JCJOJQJ^JaJ#h~h_>*CJOJQJ^JaJ,jh~h_>*CJOJQJU^JaJh)h1=0OJQJ^Jh)h :OJQJ^Jh],5OJQJ\^Jh)h1=05OJQJ\^Jh.OJQJ^JhThhOJQJ^JhhOJQJ^Jh 9OJQJ^Jh_OJQJ^JBEFOVaҺ҇zl^QzQDh)hAOJQJ^Jh)hXyOJQJ^Jh)hXy>*OJQJ^Jh)hxV5OJQJ^Jh)hxVOJQJ^Jh)h?OJQJ^Jhh~0JOJQJ^Jh~h~OJQJ^Jh~OJQJ^Jjh~OJQJU^Jh_OJQJ^Jhb@OJQJ^Jh)hb@OJQJ^Jh)h1=0OJQJ^JhbOJQJ^Jafgho%?EOTVmoqʽxndZZLh)h1=0H*OJQJ^Jhy OJQJ^JhbOJQJ^JhzOJQJ^Jh)hOJQJ^Jh\7OJQJ^Jh;4OJQJ^Jh 6h 6OJQJ^Jh)hAOJQJ^Jh[hOJQJ^Jh)h1=0OJQJ^Jh)h1=0OJQJ\^Jh\7h\7OJQJ^Jh2h2>*ϴ)Xϴ$$*ϴ)Aϴ)ϴ)1=0ϴb1=05Oϴ!*.7808Ÿvbūչչ;4;45Oϴ;45OϴB´}eZL9$jhBShBS>*OJQJU^Jh)hBS>*OJQJ^Jh>*OJQJ^J/jhBSh6Q>*OJQJU^JmHnHu*jhBSh6Q>*OJQJU^JhBSh6Q>*OJQJ^J$jhBSh6Q>*OJQJU^Jh6Qh6Q>*OJQJ^Jh6QOJQJ^Jh;4OJQJ^Jh)hOJQJ^Jh;4h;45OJQJ^Jh;4h5OJQJ^J  jlnpLN $$$$6%8%1$gdgdBS$a$gd\7$a$gdBS$a$gd*ϴ*>*ϴ;4ϴ*>*ϴ)ϴ)>*ϴ/>*ϴԱ$>*ϴ*>*ϴ>*ϴ$&:׿ױ׌v׿׌R׿׌*>*ϴ)>*ϴ*>*ϴ>*ϴ)ϴ;4ϴ;4;4>*ϴ/>*ϴԱ$>*ϴ*>*ϴ:<>HJN t v v!!!!!!!׿ױ׌v׿k^QQG:h;4h;4OJQJ^JhbYOJQJ^Jh)hbYOJQJ^Jh)hOJQJ^JhBS>*OJQJ^J*jhBShBS>*OJQJU^JhBShBS>*OJQJ^Jh;4OJQJ^Jhn#hn#OJQJ^Jh)h>*OJQJ^J/jhBShBS>*OJQJU^JmHnHu$jhBShBS>*OJQJU^J*j,hBShBS>*OJQJU^J!!""$"D"^"_"o"p"""""""""""4#X#Y#Z########$$ $$$$龫odh>*ϴ/>*ϴԱ*>*ϴ>*ϴ$>*ϴ7ϴ>ϴ-ϴ;4ϴϴ)ϴ$$$$$$$$$$$%%$%&%(%2%4%6%8%:%<%b%ůӗӌvӗh^TJ=h8}hs@UOJQJ^Jh\7OJQJ^Jhs@UOJQJ^JhOJQJ^Jh)h>*ϴ*>*ϴ%>*ϴ/>*ϴԱ*>*ϴ>*ϴ$>*ϴ)ϴ)ϴ8%:%<%&&&&''(())++++YaZa`b$a$gda?a@aEaFaTaUaVa`bɸɧɖɅӃra!j h\7OJQJU^J!jL h\7OJQJU^JU!j h\7OJQJU^J!j` h\7OJQJU^J!j h\7OJQJU^J!jt h\7OJQJU^Jh\7OJQJ^Jh)hOJQJ^Jjh\7OJQJU^J!j h\7OJQJU^J#Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group related to the practice of alcohol and drug counseling or other professional practice in ӣƵ, any other state, the District of Columbia or in any other jurisdiction?  FORMCHECKBOX Yes  FORMCHECKBOX No If the answer to any of the above questions, numbers 1 through 7, is Yes, provide a complete explanation of the circumstances leading to the action, and any supporting documentation, on separate sheets of paper. I hereby swear that the information provided above is true to the best of my knowledge. __________________________________________  FORMTEXT       Applicant Signature Date -------------------------------------------------OPTIONAL ---------------------------------------------------- Gender:  FORMCHECKBOX Male  FORMCHECKBOX  Female Race / Ethnicity: (Check all that apply)  FORMCHECKBOX  Asian  FORMCHECKBOX  African American  FORMCHECKBOX  Caucasian  FORMCHECKBOX  Hispanic  FORMCHECKBOX  Native American  FORMCHECKBOX  Other  FORMTEXT `bbbdbccccdddwddddWenn$a$gd8}dgd8}dhgd8}$a$gdgds@U$a$gds@U`bdbc>clcccccccccdddddwddط{j\OA4h8}h8}OJQJ^Jhs@Uhs@U6OJQJ^Jh)hOJQJ^Jh)hs@U>*OJQJ^J h)hs@UCJOJQJ^JaJ/jhBSh\7>*OJQJU^JmHnHu*j8 hBSh\7>*OJQJU^JhBSh\7>*OJQJ^J$jhBSh\7>*OJQJU^Jhs@UCJOJQJ^JaJ h)hs@UCJOJQJ^JaJh)hs@UOJQJ^Jhs@UOJQJ^Jdddddddddddddddddddeeeee,e-e.e*OJQJU^JmHnHuU*j\hBSh\7>*OJQJU^JhBSh\7>*OJQJ^J$jhBSh\7>*OJQJU^J!jh\7OJQJU^Jh\7OJQJ^Jh8}h8}OJQJ^Jjh\7OJQJU^J!jph\7OJQJU^J      ;0P:ps/ =!"#$% DptDText2tDText2tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3vDeCheck10hDevDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10tDText3vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10vDeCheck10tDText3^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH L`L Normal1$7$8$H$CJ_HaJmH sH tH 22  Heading 1@&22  Heading 2@&22  Heading 3@&22  Heading 4@&22  Heading 5@&22  Heading 6@&2@2  Heading 7@&DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List H@H C Balloon TextCJOJQJ^JaJ6U`6 ? 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