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Application Form for
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Governor's Appointments
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Contact Us
Phone:  602-542-2449
Fax:      602-542-0758
Email:   bc@az.gov

Click here to visit the Arizona @ Your Service Website. Arizona State Resource and Directory.
 

ARIZONA GOVERNOR'S OFFICE APPLICATION FOR BOARDS AND COMMISSIONS

The preferred method of applying for a Board or Commission is by completing the on-line application below. However, a paper application may be printed out, completed and sent by US Mail or scanned and e-mailed to bc@az.gov.

Application:
A current application and resume are required both for initial appointment or reappointment consideration.
Resume Required:
After completing and submitting the application below, a second window will give you the opportunity to submit your current resume which is required.  You can also submit it at a later time to bc@az.gov; however, your application is not considered until a resume is received.  Resumes are only accepted in Word or PDF format, pasted into an e-mail, or by hard copy mailed or hand delivered.

Instructions for Letters of Recommendations:

The Governor’s Office welcomes and needs written assessments of the applicants' skills, expertise, ethics and any other characteristic relevant to an individual's potential for an appointment. Many applicants solicit letters of reference supporting their efforts at an appointment. However, applicants are advised "more" is not necessarily "better." The Governor’s Office would prefer to receive no more than 10 substantive e-mails regarding each applicant. The preferred means of communicating recommendations to the Governor’s Office is through e-mail. Please direct any such e-mails to bc@az.gov.


* Denotes a required entry.
 
Title:
First Name: *   A value is required.Exceeded maximum number of characters. Middle Initial: Last: * A value is required.Exceeded maximum number of characters.
Spouse's Name:  Title:
Spouse's Employer:

* A value is required.Exceeded maximum number of characters.
* A value is required.State:* A value is required.Invalid 5 digit Zip Code.
County:
* Invalid phone format e.g. 6025422449

Business Name:
Title:
: * A value is required.
* A value is required.Exceeded maximum number of characters. State* * A value is required.Invalid 5 digit Zip Code.
Invalid Phone format e.g. 6025422449
Email Address: * A value is required.Invalid E-mail format.Exceeded maximum number of characters.

Correspondence Preference: Office Home

Date of Birth: * A value is required.Invalid mm/dd/yyyy Date format.
Place of Birth: Exceeded maximum number of characters.
In the event you are selected for an interview you will be required to provide your social security number. Staff will contact you personally to obtain that information.
 
Gender:  * Male Female
Ethnicity: African American Asian/Pacific Islander Caucasian
  Latino Native American Other
No Response  

Party Registration: * A value is required.Exceeded maximum number of characters.
Referred By:
   
List 3 Boards/Commissions of Interest: (List according to preference - do not use "Any")
(1) *
(2)
(3)
 
Education: (Including degrees completed) * A value is required.
 
References: (Name, Business/Company/Agency, Phone) Enter up to 3 references)
A value is required.

Affirmation of Eligibility
 

   In accordance with A.R.S. 38-201, every state officer shall not be less than eighteen years of    age, a citizen of the United States and a resident of this state.
   Do you meet these requirements?


   If No, please explain:

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   Are you currently charged with or have you ever been arrested for or convicted of any felony,    misdemeanor, or violation of the Uniform Code of Military Code of Justice?
   * Yes No

   If Yes, please explain:
   
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   To your knowledge, has any formal charge of professional misconduct ever been filed against    you by a licensing or regulatory board or by any other disciplinary body in any jurisdiction? 
   * Yes No

   If Yes, please explain:
   

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   In the past five years, have you ever been reprimanded, demoted, disciplined, placed on    probation, suspended, cautioned or terminated by an employer as a result of your alleged    consumption or use of alcohol, prescription drugs or illegal drugs?
   * Yes No

   If so, state the circumstances under which such action was taken and the background and    resolution of such action.
:
   

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   Is there any possible conflict of interest, whether financial or personal, or other matter that    would create problems or prevent you from fairly and impartially discharging your duties as    an appointee?
   *
Yes No

   If Yes, please explain
:
   

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   Is there any information that, if it came to light, would embarrass you or reflect negatively on    your appointment?

   * Yes No

   If Yes, please explain
:
   

Optional: Governor's Press Release Notification Signup: No


I certify that the facts contained in this application are true and correct to the best of my knowledge. I have reviewed the statutory requirements governing the board/commissions in which I have expressed an interest and confirm that I meet those requirements. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my qualifications and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damages that may result from furnishing the same to you. Entering my name and the date below has the same legal ramifications as a hand signed document.

 
* A value is required. * A value is required.Invalid mm/dd/yyyy Date format.

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Your rights to privacy are of utmost importance to the Governor's Office in building trust and confidence when conducting business through the Internet. The Governor's Office will attempt to protect the privacy interest of anyone who corresponds with the Governor's Office and does not wish their contact information to be made public; however, because the Governor's Office is a public entity, there can be no guarantee that such information will always be kept confidential.

 
 

   

   
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Copyright 2013 Office of Governor Jan Brewer, All Rights Reserved