GUBERNATORIAL APPOINTMENTS RESUME
Please complete the entire form and return to:
Gubernatorial Appointments, Governor’s Office, State Capitol, Des Moines, IA 50319
Phone: (515) 725-3521 Fax: (515) 725-3527 E-Mail:
To submit these materials in an alternate format (e.g., Braille, large print, etc.), please call 515-725-3521.
For use by Governor’s Office
BOARD/COMMISSION APPOINTMENT(S) DESIREDIowa Statewide Independent Living Council (SILC)
PERSONAL DATA
First Name / MI / Last Name / Salutation / .Legal Residence
City / State / Zip
Home Phone / Email Address
Employer or Business Name
Address
City / State / Zip / County
Occupation
Business Phone / Fax / Cell Phone
To assist us in providing balance and to meet our goal of increased diversity within the membership of boards and commissions, we appreciate your response to these questions. Under state and federal law, this information may not be used to discriminate against you.
Of what race or ethnicity do you consider yourself to be?
Black/African American / White/Caucasian / Latino/HispanoAsian or Pacific Islander / American Indian or Alaska Native / Other:
please specify
Birthdate: / / / / / Female / Male
Do you have a permanent physical, sensory, or mental condition that affects your major life functions? / Yes / No
Are you a parent or family member of a person with disabilities? / Yes / No
Are you a Medicaid recipient? / Are you a former Medicaid recipient?
Are you a provider of Medicaid-funded services?
Have you ever been on active duty in the U.S. Armed Forces? / Yes / No
Are you a citizen of the United States? / Yes / No
Are you registered to vote in Iowa? / Indicate political affiliation: / Democrat / Republican
Independent / No Party
Signature / Date: / / / /
This form assists the Governor and Lt. Governor in evaluating the qualifications of applicants for appointment to a board or commission. State law requires most boards and commissions be balanced according to gender and political affiliation. Geographical location and diversity is also considered. Appointments are made to most boards and commissions annually. All applications are kept on file as public information.
EDUCATION List schools attended, include high school. A current resume may be substituted for this section.
School City & State of Iowa Dates Degree/Major
EMPLOYMENT & EXPERIENCE List major paid employment & significant volunteer activities. List chronologically beginning with most recent experience. A Current resume may be submitted for this section.
Dates (from-to) Employer/Organization City & State Title/Position
INTEREST IN APPOINTMENT Describe in detail why you are interested in serving on a state board or commission. Include information about your background that supports your interest. You may complete this section on a separate sheet.
I will accept appointment if selected by the Governor and if appointed; I pledge my best efforts to resolve, before assumption of office, any conflicts of interest what would be inconsistent with my responsibilities as a gubernatorial appointee.
Signature / Date: / / / /
EXECUTIVE APPOINTMENTS-BACKGROUND INFORMATION
The following information is not required by law, and will be deemed to have been submitted to the Governor in confidence. The information contained within this application will only be used for purposes of the appointment process. This information will not be made available to public inspection (except as required by Iowa Code Chapter 22).
If your answer to any of the following is “yes,” please give full details on a separate sheet of paper.
(a) Have you ever been charged of committing any crime or violation? Do not include minor traffic offenses resulting in fines of less than $100, juvenile offenses, or offenses otherwise sealed by court order.
Yes / No(b) Have you ever been convicted or have you pleaded guilty to any crime or violation? Do not include minor traffic offenses resulting in fines of less than $100, juvenile offenses, or offenses sealed by court order
Yes / No(c) Have you ever been investigated on allegations of professional misconduct?
Yes / No(d) Have you ever been the subject of any professional disciplinary proceeding or had any professional license or permit revoked or restricted upon a finding of professional misconduct?
Yes / No(e) Is there anything else that we should be aware of?
Yes / NoThe Governor’s staff and the Iowa Division of Criminal Investigation may conduct a background investigation to obtain information about you. Please provide the following information and sign below to permit the investigation to be conducted.
First Name / MI / Last NameHome Address
City / State / Zip
Social Security Number / - - / Driver’s License Number / State
Date of Birth / / / / Place of Birth
Month Day Year / City State
Professional Licenses Held / Date Issued
I herby authorize the Iowa Division of Criminal Investigation and the Governor’s Office to obtain any and all records pertaining to me on file with the Department of Revenue, the Motor Vehicle Division, law enforcement agencies, credit references or bureaus, past and present employers, business associates, and acquaintances. I agree that this information may be utilized by the Governor’s Office for any decision that directly relates to my application for appointment to the boards or commissions that I have listed above.
Signature / Date: / / / /A
Abraham Lincoln Bicentennial Commission
Accountancy Examining Board
Adult Decatorization Oversight
African-American, Commission on the Status of
Agricultural Development Authority
Agriculture Education Council
Alcoholic Beverages Commission
Architectural Examiners, Board of
Armory Board
Arts Council
Asian and Pacific Islander Heritage, Commission on the Status of Iowans of
Athletic Training Examiners Board
B
Banking Council, State
Barber Examiners, Board of
Behavioral Science Examiners, Board of
Blind, Commission for the
Boiler and Pressure Vessel Board
Brain Injuries, Advisory Council on
Brushy Creek Recreation Area Trails Advisory Board
Building Code Advisory Council, State
C
Capitol Planning Commission
Centennial Memorial Foundation, Iowa
Child Abuse Prevention Program Advisory Council
Child Advocacy Board
Chiropractic Examiners, Board of
City Development Board
City Finance Committee
Civil Rights Commission
Clean Air Act Compliance Advisory Panel
College Student Aid Commission
Community Action Agencies, Commission on
Community College Strategic Plan Committee
Consumer Advisory Panel
Corrections, Board of
Cosmetology Arts & Sciences Examiners, Board of
County Finance Committee
Credit Union Review Board
Criminal and Juvenile Justice Planning Advisory Council
D
Deaf, Commission on the
Dental Examiners, Board of
Dependent Adult Protective Advisory Council
Des Moines River & Greenbelt
Advisory Council
Developmental Disabilities, Governor’s Planning Council on
Dietetic Examiners, Board of
Drug Policy Advisory Council
E
Early Access Council for Children and Families
Economic Advisers, Council of
Economic Development Board
Education Commission of the States
Education, State Board of
Educational Examiners, Board of
Elder Affairs, Commission of
Elevator Safety Board
Emergency Response Commission
Employment Appeal Board
Empowerment Board, Iowa
Engineering and Land Surveying Examining Board
Environmental Protection Commission
Ethics and Campaign Disclosure Board, Iowa
F
Finance Authority, Iowa
Fire Service and Emergency Response Council
Food Policy Council, Iowa
G
Grain Indemnity Fund Board
Great Places Advisory Board
H
Health, State Board of
Health Facilities Council
Health Insurance Association, Iowa Comprehensive
Healthy and Well Kids in Iowa Board (HAWK-I)
Hearing Aid Dealer Examiners, Board of
Higher Education Loan Authority
Historical Records Advisory Board, State
Historical Society of Iowa Board of Trustees, State
Hospital Licensing Board
Human Services Council
Humanities Board, Iowa
I
Independent Living Council
Indigent Defense Advisory Commission
Institute for Tomorrow’s Workforce
Interior Design Examining Board
Interpreters for the Hearing Impaired, Examining Board of
Interstate Adult Offender Supervision, State Council for
Interstate Cooperation Commission
Iowa Capital Investment Board
Iowa Cultural Trust Board of Trustee
IowAccess Advisory Council
IPERS Investment Board
J
Judicial Compensation Commission
Judicial Nominating Commission, District
Judicial Nominating Commission, State
Judicial Qualifications, Commission on
Juvenile Justice Advisory Council
L
Landscape Architectural Examining Board
Latino Affairs Commission
Law Enforcement Academy Council
Lewis & Clark Bicentennial Commission
Libraries, Iowa Commission of
Lottery Board, Iowa
M
Massage Therapy Examiners Board
Medical Assistance Advisory Council
Medical Assistance Pharmaceutical and Therapeutics Committee
Medical Examiners, Board of
Mental Health, Mental Retardation, Developmental Disabilities, and Brain Injury Commission
Mental Health Risk Pool
Midwest Higher Education Compact
Mid-America Port commission
Mississippi River Parkway Planning Commission, Iowa
Mortuary Science Examiners, Board of
N
Natural Resources Commission
Nonpublic School Advisory Committee
Nursing Examiners, Board of
Nursing Home Administrators, State Board of
O
Optometry Examiners, Board of
Organic Advisory Council
P
Parole, Board of
Peace Officers Retirement, Accident Disability Systems Trustees
Personal Assistance and Family Support Services Council
Persons with Disabilities, Commission of
Petroleum Underground Storage Tank Fund Board, Iowa Comprehensive
Pharmacy Examiners, Board of
Physical and Occupational Therapy Examiners, Board of
Physician Assistant Examiners, Board of
Podiatry Examiners, Board of
Preserves Advisory Board
Prevention of Disabilities Policy Council
Prison Industries Advisory Board
Property Assessment Appeal Board
Psychology Examiners, Board of
Public Broadcasting Board, Iowa
Public Employment Relations Board
R
Racing and Gaming Commission, State
Railway Finance Authority, Iowa
Real Estate Appraiser Examining Board
Real Estate Commission
Regents, State of Iowa Board of
Renewable Fuels and Coproducts Advisory Committee
Respiratory Care, State Board for
Rural Health and Primary Care Advisory Committee
S
School Budget Review Committee
Senior Living Coordinating Unit
Small Business Advisory Council
Social Work Examiners, Board of
Soil Conservation Committee, State
Speech Pathology and Audiology
Examiners, Board of
Student Loan Liquidity Corporation
T
Tax Review, State Board of
Technology Governance Board
Telecommunications and Technology Commission
Terrace Hill Commission
Title Guaranty Division
Tobacco Use Prevention and Control Commission
Transportation Commission
U
Uniform State Laws, Commission on
Utilities Board
V
Vertical Infrastructure Advisory Committee
Veterans Affairs Commission
Veterinary Medicine, Iowa Board of
Vision Iowa Board
Vocational Rehabilitation Council
Volunteer Service, Iowa Commission on
W
Watershed Improvement Review Board
Women, Commission on the Status of
Workforce Development Board
Workforce Investment Act, Regional Board