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Application for Executive Appointment

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If you are interested in being considered for an appointment to a Board/Commission,
please complete this application form.

*All fields must be completed before form can be sent.
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*Do not hit the enter key until you are ready to submit the form. Hit your tab key to go to the next field.
*Please note that completed applications and additional application material that you provide may be subject to public information requests.


 
Today's Date
Your Name (required)
Appointment Desired (required) (Board/Commission Name)
Please list any other Boards or Commissions which you are currently serving on or previously have served on.
 
Legal Residence (required) (house number, street name)
City
State
Zip Code
County
 
Business Address (house number, street name)
City
State
Zip Code
County
 
 
Home Phone (required) (Please include area code)
Business Phone (Please include area code)
Cell/Pager Phone (Please include area code)
FAX Number (Please include area code)
Email Address (required)
 
Place of Birth
 
Occupation
Name of Spouse
 
Are you a United States Citizen?
Yes No
Congressional District
1
2
3
Name of Your State Senator
 
Are there currently or has there ever been any disciplinary actions, suspensions or revocations of any licenses that you have been issued by any agency of federal, state, or local government?
Yes No
If yes, please explain:
 
Could you or any member of your family be affected financially by decisions to be made by the board or commission for which you have applied ?
Yes No
 
Political Affiliation
(Some appointments require specified partisan membership;
therefore we ask that you indicate your political affiliation.
)

Republican
Democrat
Independent
Other (specify)

 
Diversity Information
(To assist in the selection, you are asked to voluntarily provide information,
which is necessary for statistical reporting purposes. Under State and Federal law,
this information may not be used to discriminate against you.
)
Male
Female
 
Employment
Statutes require some board appointees meet specific employment criteria.
List employment beginning with the most recent experiences.
A resume or additional information is optional.
Employer Location Dates
 
Education
Schools attended including High School:
School Location Dates Major/Degree
 
Additional Information
Please list additional supportive information about yourself, your experiences,
and background, including any board or commission you have served on in the past,
honors or awards you have received, and other volunteer activities.
 

Areas of Interest:

Agriculture Cultural Economic Development
Education Environment Finance
Government Health Human Services
Labor Other (specify)
 
References
List names, addresses, and phone numbers of at least three people who may be contacted for references:
Name Phone Number Address
(required) (required)
(required) (required)
 

If you have recently prepared a biography or resume you may fax or email to Kathleen Dolezal:
Fax: (402) 471-6031
Email : Kathleen Dolezal (Click on Kathleen's name to open your email, or right click to copy email address and paste into an email).

USPS Mailing Address:
Kathleen Dolezal, Staff Assistant for Boards and Commissions
Nebraska Governor’s Office, State Capitol
Box 94848
Lincoln, NE 68509-4848
Phone: (402) 471-1971
Fax: (402) 471-6031

Some executive appointments are subject to confirmation by the Nebraska Legislature. One area of inquiry will be whether you or your spouse have a conflict of interest. Prior to the hearing, you may be required to complete an Accountability and Disclosure Statement. Also, an investigation into your background may be conducted by the Nebraska State Patrol prior to your appointment.

I hereby grant the Governor's Office and the Nebraska State Patrol permission to obtain, and provide the Governor, any and all records pertaining to me from the Department of Revenue, Department of Motor Vehicles, Law Enforcement Agencies, credit bureaus, past and present employers, employees, business associates, affiliations, and acquaintances.

As a citizen of the United States and a resident of this state, I will accept appointment if selected by the Governor. If appointed, I pledge my best efforts to resolve, before assumption of office, any conflicts of interest that would be inconsistent with my responsibilities as a gubernatorial appointee.

To the Governor, I submit
Enter quoted text (without quotes) (required):
I accept the above terms (required).

 

When you click 'Submit Application' this form will be sent to Kathleen Dolezal, Office of the Governor, State Capitol, Lincoln, Nebraska 68509.

If you are having problems accessing or submitting this form please Contact the Webmaster.

All other questions should be directed to the Governor's Office.


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