Gubernatorial Appointments Application

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Desired Appointment

Follow these steps to select an appointment for which you would like to be considered. To find out more about the requirements for a specific board or commission in which you are interested, please click on this link to search the Indiana Code: http://www.in.gov/legislative/ic/code.

Agency

Instruction image

Boards And Commissions

Selected Board/Commission:

Upload at least one of the following documents in Adobe Acrobat PDF format:

Resume -
Background Check Agreement -
Financial Disclosure -

Applicant Profile

Title

First Name

Middle Name

Last Name

Suffix

Have you ever used, or have you ever been known by, any other name?
If yes, provide name(s) and explain:

Email

Home Phone

Cell Phone

Work Phone

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Background Highlights (Please share any significant details which may be further explained in your resume.)

Education: (2,000 characters max)

Employment Experience: (2,000 characters max)

Professional Licenses: (2,000 characters max)

Previous Appointments: (2,000 characters max)

Honors: Please list all scholarships, fellowships, honorary degrees, honorary society memberships, and other special recognitions for outstanding service or achievements:

References: Please list the name, telephone number and e-mail address of three (3) persons who are willing to serve as references:

Military Service

List rank, date and type of discharge from active service:

Discharge: Were you discharged from military service under anything less than honorable conditions?

Yes No

If yes, please explain:

Are you a member of the Reserves or the National Guard?

Yes No

If yes, date obligation ends: MM/DD/YYYY

Vetting (all questions are required to be answered)

Business / Lobbying: Describe any business relationship, dealing or financial transaction which you have had during the last five years, whether for yourself, on behalf of a client, or acting as an agent which you believe may constitute an appearance of impropriety or could result in in a potential conflict of interest in the position to which you want to be appointed. If none, please state.

Are you or have you at any time, been a registered lobbyist?

Yes No

If yes, please provide the name of the organization(s) for which you lobbied:

Citations: Have you ever been cited for a breach of ethics for unprofessional conduct, or been named in a complaint to any court, administrative agency, regulatory body, professional association, disciplinary committee, or other professional group?

Yes No

If yes, please provide a detailed explanation:

Convictions: Have you ever been convicted of or entered a plea of guilty or nolo contendere or forfeited collateral for any criminal violation other than a minor traffic offense? (Minor traffic offenses do not include the Virginia offenses of operating under the influence of liquor, operating while impaired, reckless driving or the equivalent offenses in other states)

Yes No

If yes, please provide a detailed explanation:

Current Charges: Are you now under charges for any violation of law?

Yes No

If yes, please provide a detailed explanation:

Opposition / Associations: Do you have any expectations of any group or individual voicing concern about your possible appointment?

Yes No

If yes, please provide a detailed explanation:

Delinquencies: Are you delinquent on any federal, state, or local debt? (Include delinquencies for income, property, or other taxes, governmental loans, overpayment of benefits, required payments into or under governmental programs, and other debts or required payments to the government plus any defaults on or under loans which are or were guaranteed, insured, or subsidized by any unit of government.)

Yes No

If yes, please provide a detailed explanation:

Issues: In the last five years, have you been publicly identified, in person or by organizational membership, with a particularly controversial national, state or local issue?

Yes No

If yes, please provide a detailed explanation:

Submission of Views: In the last five years, have you submitted oral or written views to any governmental authority, whether executive or legislative, or to the news media on any particularly controversial issue other than in an official governmental capacity?

Yes No

If yes, please provide a detailed explanation:

Agency Proceedings / Civil Litigation: In the last five years, have you been, or are you presently a party of interest in any administrative agency proceeding or civil litigation, including any action regarding a professional license?

Yes No

If yes, please provide a detailed explanation:

Civil Litigation of Affiliates and Family: In the last five years, has any business in which you, your spouse or partner, any member of your household or other close family members or business associate are or were any officer, director or partner been a party to any administrative agency proceeding or civil litigation relevant to the position to which you have been appointed? (With respect to this question, you need only consider proceedings and litigation that occurred while you, your spouse, close family member or business associate were an officer of that business.)

Yes No

If yes, please provide a detailed explanation:

Legal Proceedings: Have you ever been a party or otherwise involved in any legal proceedings - civil or criminal? Include all legal proceedings in which you were a party of interest, a material witness, the subject of a complaint, were named as a co- conspirator or co-respondent, and any grand jury investigation in which you figured as a subject, or in which you appeared as a witness. Do not list proceedings in which you were merely a nominal party where no allegations of wrongdoing were alleged against you.

Yes No

If yes, please provide a detailed explanation:

Charges / Associates: Has a criminal charge been brought against any firm or organization during your affiliation with it?

Yes No

If yes, please provide a detailed explanation:

Discrimination: Has a complaint of discrimination on the basis of sex, race, religion, national origin, age or handicap ever been filed against you or against any firm or organization during your affiliation with it?

Yes No

If yes, please provide a detailed explanation:

Credit History: Have you ever experienced credit difficulties? Have you ever filed for bankruptcy, or encountered other severe financial difficulties?

Yes No

If yes, please provide a detailed explanation:

Controversy: Is there anything in your personal or professional life that would cause controversy for you or the governor during a public review of your candidacy or your service as a gubernatorial appointee?

Yes No

If yes, please provide a detailed explanation:

Civic Affiliations: Please list each organization, club, association, or group that you are, or have been a member of, in the past five years.

Political Affiliation:
Please select one:

Democrat
Republican
Independent
Other

If Other, please provide a detailed explanation:

Demographics

The following optional information is requested in order to ensure that this administration considers the talent and creativity of a diverse pool of candidates. In addition, specific backgrounds or qualifications are legally required for appointment to some boards and commissions. You may, therefore, wish to provide this information in order to ensure that you are considered for relevant boards and commissions.

Date of Birth

MM/DD/YYYY

US Citizen?

Yes No

Gender

Male Female

Person with a disability (specify)

Ethnic Group

Country of Birth

Please review your information thoroughly before clicking submit.