Governor's State of Delaware Boards and Commissions Application

State of Delaware Governor John Carney Boards and Commissions Application

Section I. Basic Information

Name:

Prefix/Title

First

M.I.

Current Residence:

Street

Last

Suffix/Designation

(i.e. Jr., Ph.D.)

P.O. Box (if applicable)

Telephone:

City Day Phone

State Cell

Zip Code Date of Birth:

Email Address:

Have you resided at your current residence less than 5 years? YES NO If yes, please list all residences for the past 5 years, excluding current residence:

County

Section II. Employment Experience Please provide your professional work history, starting with the most recent.

Employer/Company

Position/Title

Start and End Dates

Section III. Professional Licenses and Certificates

License

Date Issued/Date Expires

Status (active, inactive, pending)

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Section IV. Education Please provide your complete educational background. Dates do not have to be exact.

School Name/State

Certificate, Diploma, or Degree Dates Attended

High School

College Other

Section V. Organizations and Society Memberships Please list all organizations and societies of which you have been, or are currently, affiliated.

Organization Name

Previous Current

Section VI. Questionnaire -- Entries marked with an "*" are optional.

Do you or your spouse own real property, personal property, financial holdings or receive income from

any source which might present, or appear to present, a conflict of interest with your requested

appointment? YES NO

If yes, please explain:

Have you or your spouse ever been affiliated (as an officer, owner, director, trustee, partner, advisor or

consultant) with any institutions (corporations, firms, partnerships, business enterprises, non-profit

organizations, etc.) within the past five years which might present, or appear to present, a potential

conflict of interest with your requested appointment? YES NO

If yes, please explain:

Have you filed federal and state income tax returns for the past seven years? YES NO If no, please explain:

Have you been convicted of a misdemeanor or a felony as an adult? YES NO If yes, please explain:

Are you currently under any federal, state or local investigation for violation of a criminal law? YES NO If yes, please explain:

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Has a tax lien or other collection procedure ever been instituted against you by federal, state, or local

authorities? YES NO

If yes, please explain:

Are you only interested in a paid appointment? YES NO Required compensation (if any):

Certain boards and commissions require full disclosure of personal financial data. If required for the board or commission for which you are applying, are you willing to do so? YES NO If no, please explain:

How much time are you capable of committing to a voluntary, unpaid position?

The following questions are optional. They will enable the administration to consider the appointment of a diverse group of individuals and to meet statutory requirements of requirements of various boards:

Are you a person, or a relative of a person, with a disability? * YES

NO

If yes, please indicate which: Person with a Disability or Relative

Are you registered to vote in Delaware?* YES NO If yes, what is your Political affiliation?*

Are you a United States citizen?* YES NO If no, please identify citizenship country: *

Gender *

Ethnicity *

Section VII. Intent Please indicate the name of the desired board by using the included list. Applicants may indicate more than one board:

Board Number

Board Name

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Please explain why you wish to serve on a Board or Commission.

If applying for a specific Board or Commission, please explain what skills you would bring to enhance productivity.

Section VIII. References Please list three references who are not relatives.

Name

Phone Number

I fully understand that I alone am responsible for the accuracy and veracity of all information in this questionnaire.

Please indicate your acceptance of the above terms by typing your first and last name on the line below.

Signature of Applicant

Date

Please return to:

Office of the Governor ATTN: Lori James - Director of Boards and Commissions or Tianna Beckles ? Deputy Director 150 Martin Luther King, Jr. Blvd. South Dover, DE 19901 Telephone: (302) 744-4101 Fax: (302) 739-2775

You may scan the completed form and email to Gov_Appointments@

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BOARDNUMBER&NAME #0001 State Board of Accountancy #0002 Delaware Commission on Italian Heritage and Culture #0003 Commission on Adult Entertainment Establishments #0004 Governor's Energy Advisory Council #0005 Council on Services for Aging and Adults with Physical Disabilities #0006 Delaware Agriculture Lands Preservation Foundation #0007 Governor's Council on Agriculture #0009 Delaware Alcoholic Beverage Control Appeals Commission #0010 Behavioral Health Planning and Advisory Council #0011 Council on Apprenticeship and Training #0012 Board of Architects #0013 Architectural Accessibility Board #0014 Delaware State Arts Council #0015 Atlantic States Marine Fisheries Commission #0016 Board of Speech/Language Pathology, Audiology, Hearing Aid #0017 Council on Banking #0018 Board of The Sewell C. Biggs Collection #0019 Delaware Bicycle Council #0020 Board of The First State Preservation Revolving Fund #0021 Council on the Blind #0022 Council on Boiler Safety #0023 Committee on the Disposition of Unmarked Human Burials #0024 Delaware State Boundary Commission #0025 Delaware Cancer Consortium #0026 Statewide Labor Management Committee #0028 Board of Chiropractic #0029 Division of Developmental Disabilities Services Task Force #0030 Northeast Corridor Infrastructure & Operations Advisory Commission #0031 Delaware Interscholastic Athletic Association #0032 Cash Management Policy Board #0034 State Coastal Zone Industrial Control Board #0035 Delaware Code Revisors #0037 Education Commission of the States #0038 State Employees Charitable Campaign Steering Committee #0039 Delaware Compensation Commission #0041 Northeast High Level Radioactive Waste Transportation Task Force #0042 Delaware Health Information Network #0043 Healthy Mother and Infant Consortium #0044 Council on Correction #0045 Board of Cosmetology and Barbering #0046 Christina Gateway Corporation Board of Directors #0047 Criminal Justice Council #0048 Childhood Lead Poisoning Advisory Committee #0049 Behavioral and Mental Health Commission #0050 Developmental Disabilities Council

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