Application for H-CAP Membership

The Application Process

Please complete the following application (pages 3-7) and be sure to sign the Statement of Commitment on page 7. Return the completed form to:

Planning Group Support
Ryan White Part A Program Office
814 Jefferson Ave., Suite #3600
Memphis, TN 38103
(901)222-9450 (Office)
(901)222-8987 (Fax)



Once your application is received:

• You will receive a letter for receipt of your application.
• The Community Partnership Committee reviews all applications and each applicant with a completed application will be scheduled for a brief interview.
• The Community Partnership Committee will recommend a slate of Nominees and present the slate to the entire Planning Group for approval.
• A list of Nominees and Alternates that represent each of the required categories and adequately reflects the demographics of the epidemic will then be recommended to the Mayor of Shelby County for appointment to the Planning Group.
• Those individuals appointed by the Mayor of Shelby County to the Planning Group will have full membership and voting rights as soon as they have completed the required New Member Orientation.
• Those chosen as Alternates will also need to attend this Orientation, although they do not have permanent membership and voting rights.
• Alternates are invited to all Planning Group meetings, and will sit as voting members in place of absent Planning Group members in order to ensure that quorum is met and voting can occur.
• If your application is not selected for Planning Group membership or as an Alternate, your information will be kept on file and considered in the event that a vacancy becomes available.

If you have any questions or need more information please contact Denford Galloway, Planning Council Manager at:

Email: Phone : 901-222.9450 Fax: 901-222-8987
Address: 814 Jefferson Ave, Suite #3600, Memphis, TN 38103


Please fill out and sign this Statement of Commitment form and attach it to this submission.

Planning Group Support, Ryan White Part A Program Office
814 Jefferson Ave, Suite #3600
Memphis, TN 38103

The Group must report certain information about the structure of the membership. Please check all that apply to you and for which you self identify.

Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png txt pdf doc docx ppt pptx xls xlsx xml.