Free Secretary of the Commonwealth of Virginia - Virginia

Appointment Application

Commonwealth of Virginia

COMMONWEALTH of VIRGINIA
Office of the Governor
P.O. Box 2454 Richmond, Virginia 23218 Telephone: (804) 786-2441; Fax: (804) 371-0017

Timothy M. Kaine
Governor of Virginia

Katherine K. Hanley
Secretary of the Commonwealth

Application for Gubernatorial Appointment
Please return this application to the Office of the Secretary of the Commonwealth, Attention Appointments Division, P.O. Box 2454, Richmond, Virginia 23219; or by fax at (804) 371-0017. Please also include your resume for full consideration.
Appointment(s) for which you would like to be considered: ____________________________________________________________________________________ ____________________________________________________________________________________ Name: ______________________________________________________________________________ Title Last First Middle Have you ever used, or have you ever been known by, any other name? If yes, provide names and explain: ____________________________________________________________________________________ Home Address: ____________________________________________________________________________________ Street/City/State/Zip County Home Phone: ________________________________________________________________________ Cellular Telephone: __________________________________________________________________ Business Name: ____________________________________________________________________________________ Position Title: ____________________________________________________________________________________ Business Address: ____________________________________________________________________________________ Street/City/State/Zip County Business Phone: ______________________________________________________________________

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Appointment Application

Commonwealth of Virginia

Fax number: (Work) _____________________________(Home) ______________________________ E-Mail (please print): _________________________________________________________________ Date of Birth: _____________________________________________ Please specify citizenship status: _______________________________________________________ Registered to vote in Virginia: YES___________ NO ___________ EDUCATION (Please list all schools attended, including degree(s) and dates; if answered in full on your attached resume, please indicate):

EMPLOYMENT EXPERIENCE (If answered in full on your attached resume, please indicate):

Have you previously held, or do you currently hold any professional licenses? If so, please include numbers:

Previous government appointments, positions or elected office(s) held:

HONORS AND AWARDS (Please list all scholarships, fellowships, honorary degrees, honorary society memberships, and other special recognitions for outstanding service or achievements):

**REFERENCES (On a separate sheet, please list the name, address, telephone number and e-mail address of three (3) persons who are willing to serve as references.)

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Appointment Application

Commonwealth of Virginia

For the following questions, all "yes" answers require detailed responses, unless FULLY EXPLAINED in your attached resume. Use a separate sheet if necessary.
1. MILITARY SERVICE: List rank, date and type of discharge from active service: _______________________________________________________________________________________ _________________________________________________________________________________ a. Discharge: Were you discharged from military service under anything less than honorable conditions? If yes, please explain. YES ___________ NO ___________ b. Are you a member of the Reserves or the National Guard? YES ___________ NO ___________ If yes, date obligation ends: _________________ 2. BUSINESS RELATIONSHIPS/LOBBYING ACTIVITIES: Describe, on a separate sheet, any business relationship, dealing or financial transaction which you have had during the last five years, whether for yourself, on behalf of a client, or acting as an agent which you believe may constitute an appearance of impropriety or resulting in a potential conflict of interest in the position to which you want to be appointed. If none, please state. Also, are you, or have you at any time, been a registered lobbyist? YES _________ NO __________ 3. CITATIONS: Have you ever been cited for a breach of ethics for unprofessional conduct, or been named in a complaint to any court, administrative agency, regulatory body, professional association, disciplinary committee, or other professional group? If yes, please provide details. YES ___________ NO ___________ 4. CONVICTION: Have you ever been convicted of or entered a plea of guilty or nolo contendere or forfeited collateral for any criminal violation other than a minor traffic offense? (Minor traffic offenses do not include the Virginia offenses of operating under the influence of liquor, operating while impaired, reckless driving or the equivalent offenses in other states.) If yes, please explain. YES ___________ NO ___________ 5. CURRENT CHARGES: Are you now under charges for any violation of law? If yes, please provide details. YES ___________ NO ___________ 6. OPPOSITION/ASSOCIATIONS: Do you have any expectations of any group or individual voicing concern about your possible appointment? If yes, please explain. YES ___________ NO ___________ 7. DELINQUENCIES: Are you delinquent on any federal, state, or local debt? (Include delinquencies for income, property, or other taxes, governmental loans, overpayment of benefits, required payments into or under governmental programs, and other debts or required payments to the government plus any defaults on or under loans which are or were guaranteed, insured, or subsidized by any unit of government.) If yes, please provide details on a separate sheet of paper. YES ___________ NO ___________ 8. MEDICAL/MENTAL HISTORY: Is there anything in your medical or mental history that may be relevant to service in the position for which you seek? If yes, please provide details. YES __________ NO ____________

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Appointment Application

Commonwealth of Virginia

The following optional information is requested in order to ensure that this administration considers the talent and creativity of a diverse pool of candidates. In addition, specific backgrounds or qualifications are legally required for appointment to some boards and commissions. You may, therefore, wish to provide this information in order to ensure that you are considered for relevant boards and commissions. Gender (M/F): _______________ Person with a disability (please specify): __________________________________________ Ethnic Group/s: Asian/Pacific Islander: ________ White: ________ Arab: ____________ Indian: _________ African-American/Black: ________ Hispanic: _______ Native American: _________ Other: (please specify) __________________________

CERTIFICATION I, ________________________________________ (please print name), certify that all statements and representations provided in this statement and on accompanying materials and resume are, to the best of my knowledge, true and accurate. Signature Dated RESUME Please attach a copy of your resume to this form. Please make sure you have included all relevant work experience, education, government or military service, honors, awards and other talents, unless otherwise stated on this application. Applications should be mailed to: ______________________________________________________ ______________________________________________________

Secretary of the Commonwealth Attention: Appointments Division P.O. Box 2454 Richmond, Virginia 2321 Or by fax to: (804) 371-0017 - Attn: Appointments Division

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