Free Secretary of the Commonwealth - Virginia

SECRETARY OF THE COMMONWEALTH
Post Office Box 2454 Richmond, Virginia 23218 Phone: (804) 786-2441 Fax: (804) 371-0017

Gubernatorial Appointments Resume Form
The position to which you have been appointed is subject to confirmation by the General Assembly. To be considered by the General Assembly, certain information is needed. Please complete this form as soon as possible and return it to the Secretary of the Commonwealth. PART I: GENERAL A. Position (name of board/commission): _______________________________________________ _______________________________________________________________________________ B. Seat Description (if specified by VA Code): __________________________________________ _______________________________________________________________________________

C. Term of Appointment (as shown on appointment letter): _________________________________ _______________________________________________________________________________ D. Full Legal Name: ________________________________________________________________ E. Home Address: __________________________________________________________________ _______________________________________________________________________________ F. Home Telephone: ________________________________________________________________ G. Present Employment Position: ______________________________________________________ H. Name of Firm or Employer: ________________________________________________________ I. Business Address: _______________________________________________________________ ______________________________________________________________________________ Education: _____________________________________________________________________ ______________________________________________________________________________

J.

K. Date of Birth: ___________________________________________________________________ PART II: BACKGROUND AND INTERESTS RELEVANT TO APPOINTMENT: A. Are you being reappointed to this position? YES __________ NO __________ B. Describe, in brief, the experience, interests and other background information which qualify you to serve in the position to which you have been appointed. (You may attach any additional information you wish to bring to the attention of the General Assembly.)

DATE: ______________________ SIGNATURE:____________________________________________