Appointments Application


Applicant Info
Prefix
First Name
Middle Name
Last Name
Suffix
Alias/Maiden Name
  Not Applicable
Date of Birth
Place of Birth
Driver's License #
 
State
Social Security #

Position Sought
  Waive Salary   Waive Per Diem


Spouse Information
Full Name
  Not Applicable
Employer
Title
Work Address
City
State
Zip Code
Phone

Current Residence Address and County
Address
City
County
State
Zip Code
Phone
Fax
Email

Current Business or Professional Address
Leave blank if currently not working.
Professional Title
Business/Firm/Office
Address Line 1
Address Line 2
City
County
State
Zip Code
Phone
Mobile
Fax
Email

Voter Registration
Registered Voter?
Please Note: You have to be officially registered in your county as "American Independent" or as "Decline to State" in order to put it as your party affiliation.

Identify the party and county in which you are registered to vote:
County
Party

INFORMATION FOR REPORTING PURPOSES
To assist the Governor's Office with its reporting obligations (Gov. Code, §12011.5, subdivision (n)), applicants are asked to provide their gender and voluntarily provide their race/ethnicity. Use the categories below to choose the one with which you most closely identify.
Please identify your gender
Please state your ethnicity

Please provide your complete educational history starting with the most recent. - Dates can be approximate.

College/Law School Attended
City
Degree
Major
From: 
  - To:  


Professional Work History
Please provide your complete professional work history, starting with the most recent. Be sure to include any past gubernatorial appointments. Dates can be approximate.

Work History 1
Name of Employer
  OK to contact
Address
City
State
Zip Code
Title
Type of Partnership
Summary of job duties
Name, current phone number and address of your supervisor
Name
Phone
Fax
From: 
  - To:  
 Currently Employed


Military Service

Branch
Rank
State of Service
Service Dates: 
  - To:  


Professional Licenses and Certificates

Name
Received on: 
  - Expires on:  
 Never Expires
Details


Organizations and society memberships

Name
From: 
  - To:  
 Active Member
Details


Background and Experience
Many positions require the appointment of persons with special background, experience, etc. Please indicate below those categories for which you may qualify. Please mark only the category which specifically describes your current occupation, employment or status.
Advanced Technology
Agriculture
Attorney
Business
Communications
Education
Environment
Financial Institution
Health
Higher Education
Insurance
Labor
Law Enforcement
Legislation
Local Government
Manufacturing
Other
Small Business
Social Services
Student
Veteran
Other:
Have you resided at your current residence less than 5 years?
If yes, please list all residences for the past 5 years.
Are you a citizen of the United States of America?
If no, please identify country.
Are you a resident of California?
Have you 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.) which might present a potential conflict of interest or appearance of conflict of interest with your requested appointment?
If yes, please explain.
Have you ever been a registered lobbyist or have you lobbied at any level of government?
If yes, please explain. Include dates.
Do you own real property, personal property, financial holdings or receive income from any source which might present a potential conflict of interest or appearance of conflict of interest with your requested appointment?
If yes, please explain.
Have you filed federal and state income tax returns for the past seven years?
Have you ever been delinquent in child support payments?
Has a tax lien or other collection procedure ever been instituted against you by federal, state or local authorities?
If yes, please explain.
Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct or been the subject of a complaint to any court, administrative agency, professional association, disciplinary committee, or other professional group?
If yes, please explain.
Have you ever been involved in civil litigation, or administrative or legislative proceedings of any kind, either as plaintiff, defendant, respondent, witness or party in interest?
If yes, please explain.
Have you ever run for political office, served on a political committee, or been identified publicly with a particular political organization, candidate or issue?
If yes, please explain.
Have you been publicly identified, in person or by organizational members, with a particularly controversial national, state or local issue?
If yes, please explain.
Have you ever submitted oral or written views to any government authority or the news media, on any particular controversial issue other than in an official government capacity?
If yes, please explain.
Have you ever had any association with any person or group or business venture which could be used, even unfairly, to impugn or question your character and qualifications for the requested appointment?
If yes, please explain.
Do you know anyone who might take any steps, overtly or covertly, to oppose your appointment?
If yes, please explain.
Is there anything in your background which if made known to the general public through your appointment would cause an embarrassment to you and/or the administration?
If yes, please explain.
Can you perform the functions of this job (essential and/or marginal), with or without reasonable accommodation?
Are you applying for a position on a board or commission that the Governor is required to appoint people with disabilities?
If yes, please identify your disability.

Identify your State Senator and Assembly Member.
Senator
Assembly
If you are unsure as to your Senator or Assembly Member please visit http://findyourrep.legislature.ca.gov

Please explain why you wish to serve in the Governor's Administration

For Fair Board Appointments Only
Do you or any members of your immediate family
Are you applying for a position on a board or commission that the Governor is required to appoint people with disabilities?
Own any interest in any real property adjacent to or in proximity with the fairgrounds?
Have any interests or associations which might present a conflict of interest?
Currently serve as an elected city or county official?

For Intern Applicants Only.
Will you be receiving credit for this internship?
If yes, what is the name of program?
Applying for which term?
Availability:
Monday
 
- To
Tuesday
 
- To
Wednesday
 
- To
Thursday
 
- To
Friday
 
- To
Office of Interest
Appointments
Constituent Affairs
External Affairs
Legislative Affairs
Mailroom
Press Office
Scheduling

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