Prefix*

Mr. Mrs. Ms. Dr.

First Name:*

Middle Name:

Last Name:*

Suffix:

Have you ever used, or have you ever been known by, any other name? If yes, provide name(s) and explain:

Please list links to any social media profiles:

Email Address:

Home Phone:

Mobile Phone:

Work Phone:

Home Address

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Business Address

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Areas of Expertise:

List Agencies/Commissions Served On: (Previous/Current)

Upload a Resume:*

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Vetting

Business / Lobbying: Describe any business relationship, dealing or financial transaction which you have had during the last five years, whether for yourself, on behalf of a client, or acting as an agent which you believe may constitute an appearance of impropriety or could result in a potential conflict of interest in the position to which you want to be appointed. If none, please state.

Are you or have you at any time, been a registered lobbyist?

Yes

No

If yes, please provide the name of the organization(s) for which you lobbied:

Citations: Have you ever been cited for a breach of ethics for unprofessional conduct, or been named in a complaint to any court, administrative agency, regulatory body, professional association, disciplinary committee, or other professional group?

Yes

No

If yes, please provide a detailed explanation:

*Convictions: Have you ever been convicted of or entered a plea of guilty or nolo contendere or forfeited collateral for any criminal violation other than a minor traffic offense? (Minor traffic offenses do not include the State offenses of operating under the influence of liquor, operating while impaired, reckless driving or the equivalent offenses in other states)

Yes

No

If yes, please provide a detailed explanation:

*Delinquencies: Are you delinquent on any federal, state, or local debt? (Include delinquencies for income, property, or other taxes, governmental loans, overpayment of benefits, required payments into or under governmental programs, and other debts or required payments to the government plus any defaults on or under loans which are or where guaranteed, insured, or subsidized by any unit of government.)

Yes

No

If yes, please provide a detailed explanation:

Affiliations: Please list each organization, club, association, or group that you are, or have been a member of, in the past five years.

Demographics

The following optional information is requested in order to ensure that this administration considers the talent and creativity of a diverse pool of candidates. In addition, specific backgrounds or qualifications are legally required for appointment to some boards and commissions. You may, therefore, wish to provide this information in order to ensure that you are considered for relevant boards and commissions.

Date of Birth:

US Citizen:*

Yes

No

Gender:

Male

Female

Differently abled person (specify):

Ethnic Group:*

Undisclosed African American Arab Asian/Pacific Islander Caucasian Hispanic Indian Native American Other

Country of Birth

How did you hear about us?

Website Social Media Search Engine Friend Referral Other

By submitting this application, you agree to submit to a preliminary background check and you affirm that it contains no willful misrepresentation or falsifications and that this information given by you is true and complete to the best of your knowledge and belief. You should be aware that a false statement or misrepresentation is punishable under law by fine or imprisonment or both.