ARIZONA GOVERNOR'S OFFICE APPLICATION
FOR BOARDS AND COMMISSIONS
Instructions For Letters Of Reference And Telephone Calls:
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 Ms. Vasquez at: dvasquez@az.gov.
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| * Denotes
a required entry. |
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| Full Name * |
A value is required. Title:
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| Spouse's
Name |
Title:
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| Spouse's
Employer |
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*
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A value is required. |
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* |
A value is required.State*
A value is required.Invalid 5 digit Zip Code. |
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Invalid phone format e.g. 6025422449 |
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* |
A value is required. |
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* |
A value is required. State*
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A value is required.Invalid 5 digit Zip Code. |
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Invalid Phone format e.g. 6025422449Fax
Invalid Fax format e.g. 6025422449 |
| Email
Address* |
A value is required.Invalid E-mail format. |
| Correspondence preference:
Office
Home
Both |
| Date of Birth
* |
A value is required.Invalid mm/dd/yyyy Date format. |
| Place
of Birth |
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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.
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| Gender * |
Male
Female
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| Ethnicity: |
African American
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Asian/Pacific Islander
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Caucasian
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Latino
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Native American
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Other
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No Response |
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| Political Affiliation
*
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A value is required.
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| Legislative District
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| Referred By: |
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List 3 Boards/Commissions of Interest (List according to preference)
(1)
(2)
(3)
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| Current Employment (Title & Company/Agency)
*
A value is required.
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| 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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Have you ever been arrested or to your knowledge, have any formal charges of professional misconduct, criminal misdemeanor or a felony ever been filed against you in any jurisdiction?
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Yes
No
If Yes, please explain:
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Is
there any possible conflict of interest or
other matter that would create
problems or prevent you from fairly and impartially discharging
your duties
as an appointee of Governor Napolitano? Or, other information
that would
embarrass the governor?
*
Yes
No
If Yes, please explain:
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Optional: Governor's
Message of the Week Signup:
No
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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.
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*
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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