Appointment Application
PleasereturnthisquestionnairetotheOfficeoftheGovernor,AttentionAppointments Division, 111 SouthCapitolAvenue,P.O.Box 30013,Lansing,MI48909;by email to v;orbyfaxat(517)335-7899. Pleasesubmityourresume with thisapplication.
Position(s)forwhichyouwouldliketobeconsidered:
Name Last First Middle
Have youever used, or have youeverbeenknown by,anyother name?If yes,provide namesandexplain:
HomeAddress: Street/City/State/Zip County
BusinessName:
BusinessAddress: Street/City/State/Zip County
Position/Title:
HomeTelephone: BusinessTelephone:
CellNumber: FaxNumber:
Driver’sLicenseNumber*:
DateofBirth*: SocialSecurityNumber*:
E-MailAddress:
Spouseorpartner’sname:
Areyou:United StatesCitizen-YesNo_ Registered Voter-YesNo_
MichiganResident-YesNo
*Requiredforbackgroundcheckonly
EDUCATION(Includedegreeanddates;ifansweredin full on yourattachedresume,pleaseindicate):
EMPLOYMENT EXPERIENCE(ifansweredinfullonyourattachedresume,pleaseindicate):
Doyouholdanyprofessionallicenses?Ifso,pleaseincludenumbers:
Whatspecialskillscouldyoubringtothisposition?
Previousgovernmentappointments:
Pleaseprovideuswiththenamesofyour: MemberofCongress:
StateSenator: StateRepresentative:
Pleaselistanypersonorgroupwhomighttake overtor covertstepstoattack,evenunfairly,yourappointment:
Pleaseindicateanymatter inwhichyouareinvolvedthatisormaybeincompatiblewiththedischargeofthe duties ofthe position(s) to whichyou seektobe appointedor that mayimpair or tend to impairyour independenceof judgmentoractionintheperformanceoftheduties ofthatposition:
Thefollowingoptionalinformationiselicitedinordertoensurethatthisadministration considersthe talent and creativity of a diverse pool of candidates. In addition, specific backgrounds or qualificationsarelegallyrequiredforappointmenttosomeboardsandcommissions. You may, therefore,wish toprovidethisinformationinordertoensurethatyouareconsideredforrelevant boards and commissions.
Ethnicity: Gender: Age:
Politicalaffiliation: MilitaryService:
Personwithdisability:
CONSENT AND CERTIFICATION
Iconsenttotherelease ofinformationconcerningmyabilityandfitnessforthepositiontowhichIseektobe appointedbymyemployer(s),schools,lawenforcementagencies,andotherindividualsandorganizations. I authorizetheuseoftheinformationprovidedabovetoconductabackgroundsearch, includingtheuseof my social securitynumbertoaccess credit history,existing criminalrecordsand otherpubliclyavailableinformation.
I, (please print name), certify that all statements andrepresentationsprovidedinthisstatementandonaccompanyingmaterialsandresumeare,tothebestofmyknowledge,trueandaccurate.
Signature Dated______