NationalCenter for Training, Support, and Technical Assistance

Consultant Application Form

(please Print or Type)

Name: Title:
Self Employed/Independent Consultant:  YES  NO Incorporated  YES  NO
Name of Consulting company: ______
Address:______
City: ______State:______Zip Code:______
Business Telephone #: ( ) ______cellular telephone #: ( ) ______
Fax Number: ( ) ______E-Mail: ______
name of partner/associate:______Title:______
name of partner/associate:______Title:______
Please list AnEmergency Contact
Name (FirstLast):______
Address:______
City: ______State:______Zip Code:______
Telephone #: ( ) ______Relationship to You:______
Consulting Experience
How long have you been a consultant? (check one)
< 2 Years 2-4 Years 5-9 Years 10-15 Years  > 15 Years
Demographic Information: (check appropriate boxes)
This information is collected for statistical purposes only. Selection of consultants is based on educational qualifications, expertise, availability, cultural competency, willingness to travel, fee, and a client’s/organization’s willingness to accept your consultant services.
Gender: Male Female Transgender
Ethnicity:  African American  Latino/a Caucasian  Asian/Pacific Islander
 Native American  Other (please specify) ______
Age:  20-25  26-35  36-45  46-55  55+
Educational Background/Specialty: (check all that apply and fill in the appropriate boxes)
Specialization/Concentration / College(s)/
University(s) Attended / Year
Graduated
Bachelor’s
Master’s
PHD or Equivalent
Other
Certification
have You ever provided capacitybuilding assistance to any federal, state, or locally funded organization(s) that offer hiv prevention/treatment, addiction prevention/treatment, and/or violence prevention services?
 YES  NO
If yes, please list or attach a separate sheet with the organization name(s), address(s), telephone number(s), contact person(s), and work performed.
May we contact the organization(s) directly for reference(s)?  YES  NO
identify Geographical Area available to work in and travel to.
All Regions  Eastern Region  Southern Region  Central Region  Western Region
  • Eastern Region: CT, DC, DE, MA, MD ME, NH, NJ, NY, PA, PR, RI, VA, WV, VT, and US Virgin Islands.
  • Southern Region: AL, AR, FL, GA, KY, LA, MS, NC, NM, OK, SC, TN and TX.
  • Central Region: CO, IA, IL, IN, KS, MI, MN, MO, MT, ND, NE, OH, SD, UT, WI and WY.
  • Western Region: AK, AZ, CA, HI, ID, NV, OR, WA, and Pacific Basin: American Samoa, Federated States of Micronesia, Guam, Mariana Islands, the Republic of the Marshall Islands and the Republic of Palau.
Are you willilng to travel outside of your state of residence?  YES  NO
If so, what length of time?  1 – 2 nights  3 – 5 nights  6 nights or more
Do you have any experience working with the following populations? (check all that apply)
 Latinos  African Americans  Caucasians  Asian & Pacific Islanders
Native Americans MSM Commercial Sex Workers  Substance Users
LGBTQI2-S  Youth  Older Adults  Rural Organizations
 Other (please specify)______
Do you? (check appropriate boxes):
Speak: English Spanish Other ______
Read: English Spanish Other ______
Write: English Spanish Other ______
Translation: Please list each language for which you have experience translating and year(s) of experience you have with
each language: ______
Area of Expertise and years of expereince: Please check all that apply and list number of years of experience in the identified areas of expertise.
A: Organizational Infrastructure Development:
# of Years# of Years # of Years 
Board Development ____ Fund Development ____ Staff Development____
Conflict Resolution ____ Grant Writing ____ Strategic Planning ____
Evaluation & Quality Assurance ____ HIV/AIDS Education & Services ____ TeamBuilding ____
Executive Coaching ____ Leadership Development ____ Technology Dev. ____
Fiscal Management ____ Needs Assessments ____  Human Resources ____
General Organization Dev. ____ Cultural & Linguistic Competence____ AddictionTreatment ____
Addiction Prevention ____
Other: ______
B. Evidence Based Interventions and Support Skills Area:
Evidence Based Intervention (EBI/DEBI): Please list each EBI/DEBI inwhich you have experienceor have been trained in as well as the number of year(s) of experience. For a complete list of all EBIs/DEBIs endorsed by the Centers for Disease Control and Prevention (CDC), visit: ______
______
______
# of Years # of Years # of Years
Comprehensive Risk ____ Motivational Interviewing _____ Referral Services ______
Counseling Services (CRCS)
Testing & Counseling ____ Recruitment and Retention _____ Group Facilitation ______
 Social Network Strategy _____  Rapid HIV Testing ______
 Other (including, non-CDC endorsed EBIs):______
C. Other Areas of Expertise:
# of Years # of Years # of Years
Juvenile Justice ____ Violence Prevention ____ Peer Mentoring ______
At-Risk Youth ____ Community Youth Services ____ Youth Leadership ______
Child Neglect & Prevention ____  Gang Awareness & Prevention ____  Other:______
Questionnaire(please briefly answer the questions below):
The questions comprising this pre-screening assessment are designed to gauge your skills, abilities, and expertise as a consultant. Briefly answer each of the following questions. If necessary, you may attach additional documents or pages. Your individual responses will be kept confidential.
1. How did you hear about PROCEED Inc’sNationalCenter for Training, Support, and Technical Assistance (NCTSTA)? (For example,website posting, newspaper article, friend, PROCEED Staff, etc.)

2.Please describe your experience with providing capacity building assistance to community and faith based organizations?
3. As a CBA consultant, what would you say are your PRIMARY areas of expertise?
4. What is your experience working in the following areas: (Should you not have experience in a specific area,
please indicate “not applicable”.)
  • HIV/AIDS:
  • Addiction Prevention/Treatment:
  • Violence Prevention:
  • Youth Development:
5. Please state your fee range.
6. Are you computer and Internet literate? Are you familiar with PowerPoint? If required, would you be able to create a PowerPoint presentation on an assigned topic?
Signature: ______Date: ______
Please print your completed application and attach to it the following documents:

rev. 8/18/2010 - yd