Please print form below and mail or fax copies to: CLEAR, 403 Marquis Ave, Ste. 100, Lexington, Kentucky 40502. Fax: (859) 231-1943.

CLEAR CONSULTING SERVICE (CCS)

Consultant Application

Name                                                                                                                                             

Title                                                                                                                                                

Agency____________________________________________________________________________

Address____________________________________________________________________________

City_____________________________State___________ZipCode____________  

Please check the areas for which you want to provide consulting services:

_____ Management and Administration issues

_____ Information Systems

_____ Professional Discipline

_____ Legislative/Policy Issues

_____ Examination Issues

_____ Other_________________________________

Please list examples of your prior consulting experience:

Project Dates Location

__________________________ __________ ________________________

__________________________ __________ ________________________

__________________________ __________ _______________________

__________________________ __________ _______________________

PLEASE ATTACH TO THE COMPLETED APPLICATION FORM

Ø Current resume

Ø Report writing sample

Ø Names, addresses and telephone numbers of two individuals familiar with your consulting ability

MAIL TO: CCS Program Coordinator, c/o CLEAR, 403 Marquis Avenue, Suite 100, Lexington, Kentucky 40502. Your application and credentials will be evaluated by the ad hoc Consultant Selection Committee which will notify you of its decision. If you are accepted for inclusion in the CCS expert pool, you will become eligible to participate on CCS teams as opportunities arise.