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Employment Professional of the Quarter

Please note: If left open for a long time, this form will "time-out". You may want to type your nomination description in Word or Notepad, then copy and paste it into this form.

Nominee Information:

Name of Employment Professional:

Employer: Phone:
Address:  
City: Zip Code: A value is required.Invalid format. manditory

Nominator Information:

Name of Nominator: Phone:
Relationship to Nominee:  
Address:  
City: Zip Code: A value is required.Invalid format. manditory

Please give a detailed description of the nominee’s commitment to supporting individuals with mental illness with their employment goals:

.

One employer will be selected for each quarter in 2009 Please submit your nominations by 5:00 pm on the last businesses day of the quarter (March 31, June 30, September 30, and December 31).

If you have any questions please feel free to contact:
Melanie Green
Consumer Support Specialist
Clark County Regional Support Network
(360) 397-2130
melanie.green@clark.wa.gov

Clark County Community Services: Vanessa R. Gaston, Director
Street address: 1601 East Fourth Plain Boulevard, Suite C214, Vancouver, WA 98661
Mailing address: P.O. Box 5000, Vancouver, WA 98666-9810
Main phone: (360) 397-2130 | FAX: (360) 397-6028
E-mail: Community.Services@clark.wa.gov
Community Services Fraud and Abuse Hotline
The Fraud and Abuse Hotline number is (360) 397-8030 and is for the reporting of suspected fraud or abuse related to payment for services. Messages may be left anonymously. To speak directly with the Department Compliance Officer, call (360) 397-2075 ext. 7840.
Responsible Elected Official: Board of Clark County Commissioners

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