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: 

Biographical Information

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:   

County: 

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: 

 

Professional Information

Present Employer (Company/Business Name):    Business Address: 

Job Title/Responsibilities:  

Identify all of your professional license(s) below. Email a copy of each document to ccmain@dhhs.nv.gov


Type of License

License#

Issue Date
Continuously Active  since Issuance?
(if no, send letter of explanation separately)
   ccmain@health.nv.gov
   ccmain@health.nv.gov

Educational History

Specify school attended, year of graduation and type of degree received.

High school or high school equivalence (G.E.D.): 

Undergraduate: 

Graduate: 

 

Background Information

If you answer "yes" to any question below, please mail explanations with the documents to be downloaded, printed and mailed in the section below.

  1. 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?  
  2. Are you or any organization that employs you a recipient of any state grant monies?  
  3. Is there anything in your past about which you think the Department of Health and Human Services should know? 
    If yes, please explain:

       
  4. Are you aware of any conflict of interest that might result from your appointment? 
  5. Do you serve on any local or state board, commission, council, authority, or in any elected office?.  
    If yes, please list: