GenLog - Detail page

Boards and Commissions Application Logging

System Information

Logging Type:

Logging Item:

Create Date:

Board

Note: Complete fields as appropriate below. This is one of two screens. After clicking the SAVE button, you will have an opportunity to attach additional files to this application. Resumes should be in PDF, DOC, or RTF format.
A resume or brief biography is required as part of this application. Have this ready to attach at the completion of this application process.
At this time, you cannot return to complete this document at a later date.

1.Board/Commission

2.Board/Commission

3.Board/Commission

Demographics

Title (Mr. Ms. Mrs.)

First Name

Middle Init.

Last Name

Address

City

State

Zip Code

County

Congressional District

Resident Phone

Mobile Phone

Email Address

Birth Date (mm/dd/yyyy)

Current Employer

Occupation

Business Address

Business City

Business State

Business Zip Code

Business Phone

Business Fax

Spouse's Name

Spouse's Employer

This information is necessary for certain boards in regard to racial and/or political balance. These elements are defined by statute for each board.

Party Affiliation

Ethnicity

Gender

Education and General Qualifications

Did you Graduate High School? YesNo

High School

No. Years Attended HS

Did you attend College? YesNo

Name of College/Other

Major Course of study

Minor Course of Study (option)

No. Years Attended

Did you Graduate from College with a degree? YesNo

Include memberships and positions in organizations or political parties. Indicate any public office held.

Membership in Organization 1

Membership in Organization 2

Membership in Organization 3

Have you ever been conficted of a Felony? YesNo

If yes then Comment

References

Reference Name 1

Reference Address 1

Reference Phone Number 1

Reference Years Acquainted 1

Reference Name 2

Reference Address 2

Reference Phone Number 2

Reference Years Acquainted 2

Verification

I attest that the information provided above is accurate as submitted YesNo*

Click on the save button to continue and attach a resume/vitae.

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