Nebraska Governor Dave Heineman

Application for Executive Appointment

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

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Today's Date

*Your Name

*Appointment Desired (Board/Commision Name)

Please list any other Boards or Commissions which you are currently serving on or previously have served on.

*Legal Residence (house number, street name)

City

State

Zip Code

County

Business Address (house number, street name)

City

State

Zip Code

County

*Home Phone (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

Date of Birth (Ex. 03/08/2004)

Place of Birth

Social Security Number (optional)

Occupation

Name of Spouse

Are you a United States Citizen?
Yes No

Congressional District
1
2
3

Name of Your State Senator

Have you ever been convicted of a felony or misdemeanor?
Yes No

If yes, please explain:

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)

Affirmative Action 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 no be used to discriminate against you.)
Male
Female

Racial/Ethnic Background :

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
*	*
*	*

If you have recently prepared a biography or resume, you may fax this to 402-471-6031 or email to: Peggy King, Staff Assistant for Boards and Commissions, Nebraska Governor’s Office, State Capitol, Box 94848, Lincoln, NE 68509-4848.

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. 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.

* I accept the above terms.

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

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