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______