Governor Chris Gregoire | Application for Gubernatorial Appointment to a Board or Commission

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Application for Gubernatorial Appointment to a Board or Commission

First Name *

Last Name *

Middle Name

Please choose the board or commission for which you would like to be considered: If you cannot find the Board or Commission above, please use the space below to type the name: Board Name

Contact Information

Address Line 1 * Address Line 2 City * State * Zip Code * County *

Home Phone Number * ( ) - Home Cell Number ( ) - Email Address *

May we contact you via email regarding your application? Yes No How may we best contact you?

Email Business phone Home phone Home cell

Find your legislative and congressional district

Legislative district in which you reside * Congressional district in which you reside *

Education

High School *		College
Graduated Yes No	Year graduated	Graduated Yes No	Year graduated
		Degree

Current Employment

Job Title Employer
Address Line 1 Address Line 2 City State Zip Code County		Work Phone ( ) - ext. Work Fax ( ) - Email Address Employment Date (mm/dd/yyyy) Contact Person Contact Phone ( ) - ext.
Professional Licenses held (if applicable)

References

Professional Reference 1 Name * Title * Relationship * Phone Number * ( ) - ext.	Professional Reference 2 Name * Title * Relationship * Phone Number * ( ) - ext.

Personal Reference 1 Name * Title Relationship * Phone Number * ( ) - ext.	Personal Reference 2 Name * Title Relationship * Phone Number * ( ) - ext.

Previous employment or experience (limit 256 characters)

Memberships in professional, civic organizations or government boards or commissions
(please include offices held and dates of terms) (limit 256 characters)

Community service/volunteer activities (limit 256 characters)

Could you or your family be affected financially by decisions made by the board or commission for which you are applying? Yes No If yes, please explain (limit 256 characters)

Board or commission meetings are held during the day.
Are you able to come prepared and actively participate in day meetings? Yes No

Why do you want to serve on this board or commission? (limit 256 characters) *

Personal Information

Gender Female Male Birth date (mm/dd/yyyy)	Are you a citizen of the United States? Yes No Are you registered to vote in Washington state? Yes No
Have you ever been convicted of or found to have committed a crime or offense? (Do not include traffic offenses for which the fine was less than $200.00) Yes No If yes, please explain (limit 256 characters)

Race Information

Disability Information

Do you have a permanent physical, sensory, or mental condition that limits your major life functions, such as working, caring for yourself, walking, doing things with your hands, seeing, hearing, speaking, and learning? Yes No

If yes, please explain (limit 256 characters)

Veteran Information

Have you ever been on active duty with the U.S. Armed Forces? Yes No Branch of Service Type of Discharge Campaigns

I hereby authorize that my criminal record history and tax records be released to the Governor or the Governor's representative and certify that the information provided in this application is true, correct, and complete to the best of my knowledge.

Date * (mm/dd/yyyy)

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Alaskan Native American Indian If you are American Indian or Alaska Native, please check one box below: Aleut Eskimo If you are American Indian, please list your enrolled or principal tribe:		Latino(a), Hispanic or Spanish If you are Latino(a), Hispanic, or Spanish, please check one box below: Cuba Mexican, Mexican-American, Chicano Puerto Rican Other Latino(a), Hispanic, or Spanish group, such as Colombian, Dominican, etc.:

Asian or Pacific Islander American If you are Asian or Pacific Islander, please check one box below: Asian Indian Chinese Filipino Japanese Korean Vietnamese Other:		Black/African American White/Caucasian Other Race: