Survey - Heartland Executive Leadership Council Survey

1. Your Contact Information:

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Date of Birth:

Gender:

Field Is Required Email:

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Yes, I would like to receive e-mail from Autism Speaks

Keep me logged in. What's this?

2. Field Is Required Company

3. Field Is Required Work Address

4. Field Is Required Work Phone

5. Race/Ethnicity

6. Field Is Required Please provide a brief description of your leadership experience or copy and paste bio/resume below.

7. Field Is Required Do you have any personal connection to Autism? If so, please describe:

8. Field Is Required Other Boards/Councils/Committees you have served on in the past and/or currently serve on. Please list below:

Please read the Autism Speaks Executive Leadership Council Overview & Purpose. It describes the responsibilities that will be expected of you.

9. Field Is Required I understand the Council responsibilities and would like to be considered for service.