Board Appointments

Contact Information

Have you ever used, or have you ever been known by, any other name?  If yes, provide name(s) and explain:

 

 

Home Address

 

Business Address

 

 

Social Media

Please provide the username for any social media pages you manage.

 

Please explain why you wish to serve on a board or commission: (2,000 characters max)

Experience

Please provide a brief summary/listing of your experience, education and achievements. It is helpful if you highlight any experience that is relevant to the boards for which you are applying.

Education: (2,000 characters max)

Employment Experience: (2,000 characters max)

Professional Licenses: (2,000 characters max)
Licensure is required for appointment to some boards. Please include your license number.

Previous Appointments to State boards or commissions: (2,000 characters max)

Honors: Please list any memberships, awards or achievements.

References: Please list the title, name, telephone number and e-mail address of three (3) persons who are willing to serve as references:      
# Title Name Number Email
1
2
3

 

Military Experience  

List rank, date and type of discharge from active service:

Discharge: Were you discharged from military service under anything less than honorable conditions?
Yes No If yes, please explain:

Are you a member of the Reserves or the National Guard?
Yes No

Vetting  (all questions are required to be answered)

Answering yes to any of these questions does not automatically disqualify you, but it provides us background before proceeding with an appointment.

Business / Lobbying: Describe 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 could result in a potential conflict of interest in the position to which you want to be appointed. If none, please state.

Are you or have you ever been a registered lobbyist?
Yes No

If yes, please provide the name of the organization(s) for which you lobbied:

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?
Yes No

If yes, please provide a detailed explanation:

Convictions: 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)
Yes No

If yes, please provide a detailed explanation:

Current Charges: Are you now under supervision for any violation of law?
Yes No

If yes, please provide a detailed explanation:

Opposition / Associations: Do you have any expectations of any group or individual voicing concern about your possible appointment?
Yes No

If yes, please provide a detailed explanation:

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 where guaranteed, insured, or subsidized by any unit of government.)
Yes No

If yes, please provide a detailed explanation:

Issues: In the last five years, have you been publicly identified, in person or by organizational membership, with a particularly controversial national, state or local issue?
Yes No

If yes, please provide a detailed explanation:

Vetting  (all questions are required to be answered)

Submission of Views: In the last five years, have you submitted oral or written views to any governmental authority, whether executive or legislative, or to the news media on any particularly controversial issue other than in an official governmental capacity?
Yes No

If yes, please provide a detailed explanation:

Agency Proceedings / Civil Litigation: In the last five years, have you been, or are you presently a party of interest in any administrative agency proceeding or civil litigation, including any action regarding a professional license?
Yes No

If yes, please provide a detailed explanation:

Civil Litigation of Affiliates and Family: In the last five years, has any business in which you, your spouse or partner, any member of your household or other close family members or business associate are or were any officer, director or partner been a party to any administrative agency proceeding or civil litigation relevant to the position to which you have been appointed? (With respect to this question, you need only consider proceedings and litigation that occurred while you, your spouse, close family member or business associate were an officer of that business.)
Yes No

If yes, please provide a detailed explanation:

Legal Proceedings: Have you ever been a party or otherwise involved in any legal proceedings - civil or criminal? Include all legal proceedings in which you were a party of interest, a material witness, the subject of a complaint, were named as a co- conspirator or co-respondent, and any grand jury investigation in which you figured as a subject, or in which you appeared as a witness. Do not list proceedings in which you were merely a nominal party where no allegations of wrongdoing were alleged against you.
Yes No

If yes, please provide a detailed explanation:

Charges / Associates: Has a criminal charge been brought against any firm or organization during your affiliation with it?
Yes No

If yes, please provide a detailed explanation:

Discrimination: Has a complaint of discrimination on the basis of sex, race, religion, national origin, age or handicap ever been filed against you, or against any firm or organization during your affiliation with it?
Yes No

Discrimination

Credit History: Have you ever filed for bankruptcy, or encountered other severe financial difficulties?
Yes No

If yes, please provide a detailed explanation:

Financial Stake: Do you or any member of your household have any business that comes under this board?
Yes No

If yes, please explain:

Controversy: Is there anything in your personal or professional life that would cause controversy for you or the governor during a public review of your candidacy or your service as a gubernatorial appointee?
Yes No

If yes, please provide a detailed explanation:

Affiliations: Please list each organization, club, association, or group that you are, or have been a member of, in the past five years.

"Citizen Member" Seats:  Answer this question only if you are applying for a seat as a citizen member or a member of the general public on a regulatory board. According to the Virginia Code, section 2.2 - 2102, a "citizen member" must be a person who: (i) is not by training or experience a practitioner in the subject area of concern to the board or commission, (ii) is not the spouse, parent, child or sibling of such a practitioner, and (iii) has no direct or indirect financial interest, except as a consumer, in the subject area of concern to the board or commission.
Yes No

Do you qualify for a citizen member seat based on the criteria above?

Please review your information thoroughly before clicking submit.
You will receive a confirmation email when your application is successfully submitted.