APPLICATION FOR APPOINTMENT TO POSITION OF TRUST
Completion of this application and a successful background check is a requirement for your appointment by the Governor to a Board, Commission, Committee, Authority, or other Position of Trust. Information submitted on this form may be subjected to public disclosure under NRS Chapter 239, Public Records. Note: All fields are required fields. If a field doesn't apply to you please enter N/A.
Applying for (Name of Board, Commission, Committee, Authority, General Area of Interest, or Specific Position of Trust):
Please specify which position on the board/commission you qualify for:
Legal Last Name: Legal First Name: Legal Middle Name:
Title: (check only one): Preferred Name:
Have you ever been known by any other legal name?
If 'Yes' list and explain:
Date of Birth: Place of Birth: Ethnicity:
Are you U.S. Citizen: If "No" explain:
If you are a naturalized citizen, date of naturalization: If "Yes", list place of birth:
Are you a Veteran:
Spouse's Name: Names and ages of Children:
Preferred Contact Address: Residence Address:
Email: Home Phone: Cell Phone:
Since what year have you been a continuous resident of Nevada? Number of years at current residence?
If less than 5 years, list the city you resided during the last 5 years:
Present Employer (Company/Business Name): Business Address:
Identify all of your professional license(s) below. Email a copy of each document to firstname.lastname@example.org
Specify school attended, year of graduation and type of degree received.
High school or high school equivalence (G.E.D.):
If you answer "yes" to any question below, please mail explanations with the documents to be downloaded, printed and mailed in the section below.
- Have you ever had a grievance or complaint filed with any board that regulates your professional license(s), or had a professional license suspended, revoked or modified?
- Are you or any organization that employs you a recipient of any state grant monies?
- Is there anything in your past about which you think the Department of Health and Human Services should know?
If yes, please explain:
- Are you aware of any conflict of interest that might result from your appointment?
- Do you serve on any local or state board, commission, council, authority, or in any elected office?.
If yes, please list: