Aide/Speaker/Trainer/Mentor/Consultant Name:

Address:

City:		State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip-Code:

Daytime Phone:		Eveving Phone:		Wireless Phone:

E-mail Address:

Date of Birth:		Social Security Number: (Needed to issue 1099's)

What hours are you available for this program?:

Please list your education, degrees and honors for for grant purposes:

Any Additional Information:

Please Note:

All materials, documents, procedures, know-how developed for this program are done so as a work-for-hire created for PVBIA and POAC-NoVA, Inc. POAC-NoVA, Inc. shall exclusively own and control these items.

Events including workshops and classes may be videotaped. POAC-NoVA, Inc. shall exclusively own and control these videos.

NOTE: All Trainers, Consultants, Mentors, Aides and Speakers are working as 1099 Consultants or they are paid through their respective Companies and they are not employees of POAC-NoVA, Inc..

Additional Documentation should be sent to the POAC-NoVA Member Resource Center:

Parents Of Autistic Children of Northern Virginia (POAC-NoVA)
ATTN: PVBIA Advanced 2.0
3927 Old Lee Highway
Suite 102-C
Fairfax, VA 22030-2422