Completeand Return to:BoardsandCommissions77SouthHighStreet

30thFloor

Columbus,OH43215

Phone:(614)466-3555

Fax:(614)466-9354

JOHNR. KASICHGOVERNORSTATEOFOHIO

TheStateofOhioisanequalopportunityemployerandwillnotuseanyoftheinformationyouprovidetodiscriminateagainstyouonthebasisofrace,color,religion,sex,nationalorigin,handicap, age,orancestry.Ifyouneedmorespacetoanswer anyquestionorexplainanyofyouranswers,pleaseuseadditionalsheets.ThisinformationMUSTBECOMPLETEDIN FULL.Answer“none” or“notapplicable”where appropriate.

  • INADDITIONTOTHISFORM,PLEASESENDARESUMEORSHORTBIOGRAPHYTOTHEABOVEADDRESS OREMAILTO 

FullName:

Residence Address:

City:State:Zip code:

County of Residence:Length of Residence inOhio:

Phone Numbers(Home):(Cell):(Business):

E-Mail Address:

Current Business / Employer:

BusinessAddress:

City:State:Zip code:

[] / White:Allpersonshaving originsin any of theoriginal peoples of Europe, North AfricaortheMiddleEast.
[] / BlackorAfricanAmerican:All persons havingoriginsin any of theBlack racialgroupsof Africa.
[] / HispanicorLatino:All persons of Mexican, Puerto Rican, Cuban, CentralorSouthAmericaorother Spanishculture ororigin, regardless ofrace.
[] / Asian: All persons havingorigins in anyoftheoriginal peoples of theFarEast, SoutheastAsia, the IndianSubcontinent(for example, China, India,Japan, andKorea).
[] / NativeHawaiian orPacific Islander:Allpersons having origins inanyof theoriginal peoples of theHawaiianIslandsandPacific Islands(for example,Hawaii, Philippine Islands, andSamoa).
[] / American Indian orAlaskanNative:Allpersons havingorigins inanyof the original peoples of North Americaandwho maintain cultural identificationthrough tribal affiliation or communityrecognition.
[] / Other:Pleaseselfdefine:

Pleasespecifythe boardorcommission that interestsyou:

Doyoucurrently serve ona gubernatorialboardorcommission?If yes, pleaseidentify:

Are youseekingreappointment?Yes []No[]

Have you everbeen a memberof thearmedforcesof the United States,itsreserve componentsortheNationalGuard?If yes, pleasestate branch, service period, andlastrank,andplease indicateifyoudidnot receiveanhonorabledischarge, wereevercourt-martialed, wereeverassessednon-judicialpunishment, resignedinlieuof court-martial, orwereadministratively discharged:

Are younowunderany chargeorchargesforany crime?If yes, pleaseidentify:

Have you ever,asanadult, beenchargedwith anycrimeorarrestedforany crime(regardlessofwhetheryouwereconvictedoracquitted)excludingminortrafficoffenses?If yes, please identify:

Hasany civillitigationorgarnishment actioneverbeen filedagainstyou? If yes, pleaseidentify:

Hasany civilprotectionorder(CPO)orrestrainingorderoremergencycustody orderrelatingtodomesticviolenceorany other subjecteverbeenenteredagainstyou? If yes, pleaseidentify:

Have you everhadany civil, administrative, orarbitrationjudgment orgarnishment enteredagainstyou oragainst any businessinwhichyouwere owner orthemajorityshareholder?If yes, pleaseidentify:

Have you everfiledpersonalbankruptcyorbeenadjudicatedbankrupt? If yes, pleaseprovidedetails:

Are youcurrently in arrears onany court-ordered childsupport payments?If yes, pleaseidentify:

Hasanybusinessthat youhaveowned,orof whichyouhave been the majority shareholder,everfiledforbankruptcy orbeen adjudicatedbankrupt? Ifyes, pleaseidentify:

Have you ever failedto pay any government-insureddebt orany debt owedto agovernment entity? Ifyes, pleaseidentify:

Have you everappliedfor, orheld a license fora business, trade, orprofessionthat required proof ofgoodcharacterorexamination? If yes, pleaseidentifythelicenseandissuingauthority:

Have you everbeendenied sucha license, hadthat licenserevoked orsuspended, orbeendisciplinedwithrespecttothat license?

Have you everbeendisciplined for, orhasany actioneverbeentakenagainst youby any publicorlicensingauthorityorprofessionalorganization for any breachof ethicsorunprofessionalconductorfailure tomake required disclosures? Ifyes, pleaseidentify:

Are all of your federal, stateandlocaltaxescurrent?If no, pleaseexplain:

Within thepastthreeyears, hasany businessventure for whichyouwerean ownerorpersonresponsibleforremittingwithholdingtaxesof salestaxes, failedto pay such taxesin a timelymanner?If yes, pleaseexplain:

Have you ever received, otherthanasanemployee,orhasany businessthat you ownedorofwhichyou werethe majority shareholder, everreceivedanyincomefrom the Ohio stateboardorcommissiontowhichyouseekappointment?If yes, pleaseidentifytheincome:

Haveyou ever received income as a lobbyist or “legislative agent:as defined intheOhioRevisedCodesection 101.70 or “executiveagencylobbyist”as defined in OhioRev. Code section121.60for workrelatedtotheOhio GeneralAssembly, any Ohioelectedofficerorany agency orentityof theexecutivebranchof theOhiostate government? Ifyes, pleaseidentifythe entityreceivingtheincome:

Are you a United StatesCitizen?If no, pleasestateimmigrationstatus:

Doeitheryou oryourspouseownorare eitheryouoryour spousethemajority shareholderofanybusinessthatwill deriveincomefromthe Ohio stateboardorcommissiontowhichyouseekappointment?If yes, pleaseidentifythebusinessand theamountof annualincome anticipated:

Doyouhave,orhaveyouhad, any personal,financialorbusinessinterestordealings thatmightpresent a conflictof interest with yourproposedstate appointment? If yes, pleaseidentify:

Identifyanddescribeany other informationorsituationthat others might perceiveas aconflictof interestwithyour proposed state appointment, orwhichmight causeembarrassment tothestate shouldyoubeappointedto astate boardorcommission:

Have you beenpubliclyidentifiedwith aparticularly controversialnational, state,orlocalissue, orwithanissueunderthesupervisionof theboardorcommissiontowhich youseekappointment?If yes, pleaseexplain:

EDUCATION/TRAINING(Useseparate sheet of paper ifnecessary)

HighSchoolName: / Location(City,State): / Didyougraduate?]Yes]No
CheckYearCompleted:]9]10]11]12 / ObtainedGED?]Yes]No
SchoolName(College/University): / Location(City,State):
Didyougraduate?YesNo / CheckYearCompleted:123456 / Major:
SchoolName(College/University): / Location(City,State):
Didyougraduate?YesNo / CheckYearCompleted:123456 / Major:
SchoolName(College/University): / Location(City,State):
Didyougraduate?YesNo / CheckYearCompleted:123456 / Major:

PLEASE LISTRELEVANTWORKEXPERIENCE:

1.

2.

3.

I,, certifythat all of the answersandstatements onthis form are true, completeandcorrectto the best of myknowledgeand recollectionandaremade in good faith.

SignatureofApplicant

I,, statethatI understandthatanyinformationprovided to the Governor’s officemaybea “public record”underOhiolaw.Iherebywaiveanyright to privacyof anyinformation Ihaveprovided herein, and I authorize the Governor’s office toinvestigate anyof myresponses.

SignatureofApplicant

Completeand Return to:BoardsandCommissions77SouthHighStreet

30thFloor

Columbus,OH43215

Phone:(614)466-3555

Fax:(614) 644-09516