TOWN OF RIVERHEAD

200 Howell Avenue

Riverhead, NY 11901
(631) 727-3200

ANTI-BIAS TASK FORCE

HOTLINE: (631) 727-3200 x550
Email: abtf@townofriverheadny.gov

TOWN OF RIVERHEAD
ANTI-BIAS TASK FORCE

APPLICATION FOR MEMBERSHIP

NAME:___________________________________________________________
______________________________________________

MAILING
ADDRESS:________________________________________________________
_______________________________

__________________________________________________________________
_______________________________________________

Email:
__________________________________________________________________
______________________________________

Home Phone:
__________________________________________________________________
_____________________________

Cell Phone:
__________________________________________________________________
________________________________

Affiliations/Interests:
__________________________________________________________________
____________________

__________________________________________________________________
_______________________________________________
Town Of Riverhead
ANTI-BIAS TASK FORCE

__________________________________________________________________
_______________________________________________

Would you be willing to receive training on the subject of bias,

prejudice and/or community relations?
_______________________________________

Have you received any training and if so, please

specify?__________________________________________

__________________________________________________________________
_______________________________________________

DEADLINE FOR SUBMISSION: October 20, 2017

PLEASE ATTACH RESUME AND LETTER OF PERSONAL
INTENT
Email all 3 to ABTF chair Connie Lassandro:
cmlassandro@aol.com

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