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

Position:

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

Personal Mobile

Fax

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

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?