![]() I will accept appointment if selected by the Governor and if appointed I pledge my best efforts to resolve, before assumption of office, any conflicts of interest what would be inconsistent with my responsibilities as a gubernatorial appointee. You may complete this section on a separate sheet. Information about your background that supports your interest. INTEREST IN APPOINTMENT Describe in detail why you are interested in serving on a state board or commission. Dates (from-to) Employer/Organization City & State Title/Position A Current resume may be submitted for this section. List chronologicallyīeginning with most recent experience. School City & State of Iowa Dates Degree/MajorĮMPLOYMENT & EXPERIENCE List major paid employment & significant volunteer activities. A current resume may be substituted for this section. All applications are kept on file as public information.ĮDUCATION List schools attended, include high school. Appointments are made to most boards and commissions annually. Geographical location and diversity is also considered. State law requires most boards and commissions be balanced according to gender and political affiliation. ![]() Governor in evaluating the qualifications of applicants for appointment to a board or commission. Indicate political affiliation: Democrat_ Republican_ No Party_ Armed Forces? Are you a citizen of the United States? Yes No Are you registered to vote in Iowa? Yes No Of what race or ethnicity do you consider yourself to be? Black/African-American White/Caucasian Asian or Pacific Islander American Indian or Alaska Native Birthdate: Latino/Hispano Other_ĭo you have a permanent physical, sensory, or mental condition that affects your major life functions? Are you a parent or family member of a person with disabilities Yes No Are you a Medicaid recipient? _ Are you a former Medicaid recipient? _ Are you a provider of Medicaid-funded services? _ Have you ever been on active duty in the U.S. Under state and federal law, this information may not be used to discriminate against you. To assist us in providing balance and to meet our goal of increased diversity within the membership of boards and commissions, we appreciate your response to these questions. Please complete the entire form and return to: Gubernatorial Appointments, Governor’s Office, State Capitol, Des Moines, IA 50319 Phone: (515) 281-0215 Fax: (515) 281-0217 To submit these materials in an alternate format (e.g., Braille, large print, etc), please call 51 For use by Governor’s Officeįirst Name Legal Residence City Home Phone Employer or Business Name Address City Occupation Business Phone Fax Cell Phone State Zip County State Email Address Zip County MI Last Name Salutation
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