TRIAL MEMBERSHIP APPLICATION Name of County/Township Board or Association: Please enter county name* Address City State Zip Telephone: FAX: Please enter telephone number* Key Contact Position: E-Mail: Please enter Email* Check All that Apply 708 Board 553 Board 377 Board Group initiating referendum Mental Health Committee Please check atleast one option* Total Budget for current fiscal year * $ * Include here your TOTAL from all sources of funds including monies generated from non-levy sources (federal dollars, etc.). Please fill this field . TOTAL derived from tax levy, interest income and personal property replacement tax (if any) $ Fiscal Year: Begins Ends Levy Rate ** ** Include here the actual tax rate at which your board is levying during the current fiscal year. BOARD/STAFF MEMBERS Name Organization E-mail Add More AGENCIES OR PROGRAMS FUNDED* Mental Health Services Developmental Disability and Intellectual Disability Services Substance Use Treatment and Related Services Other Please check atleast one option* Please verify reCAPTCHA
