Please explain why you wish to serve on a board or commission. (Max 2000 characters)

Education (Max 2000 characters)

Employment (Max 2000 characters)

Professional Licenses (Max 2000 characters)

Appointments (Max 2000 characters)

Honors (Max 2000 characters)

Reference 1 Title

Reference 1 Name

Reference 1 Email

Reference 1 Phone

Reference 2 Title

Reference 2 Name

Reference 2 Email

Reference 2 Phone

Reference 3 Title

Reference 3 Name

Reference 3 Email

Reference 3 Phone

Military Experience List rank, date and type of discharge from active service

Military Discharge: Were you discharged from military service under anything less than honorable conditions?
Yes No

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

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.

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

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

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

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

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

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

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

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

Proceedings: 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

Civil Litigation: 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

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

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

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

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

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

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

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

"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