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APPLICATION FOR APPOINTMENT TO HENDERSON COUNTY BOARDS &

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APPLICATION FOR APPOINTMENT TO HENDERSON COUNTY BOARDS & COMMITTEES
The Henderson County Board of Commissioners invites all Henderson County residents to participate in governmental decision making by serving as a
member of a Board or Committee. The Clerk to the Board of Commissioners maintains a current list of County appointment opportunities in the
Henderson County Offices. All applications are provided to the Board of Commissioners and every possible effort is made by the Commissioners to
appoint appropriately and for the best benefit of every citizen.
Full Name: ____________________________________________ E-Mail: ________________________________________
Complete Street Address (Street Name if PO Box) ____________________________________________________________
Complete Mailing Address (if different) ____________________________________________________________________
Home Phone: ______________________ Work Phone ______________________ Cell Phone ________________________
Do you live within a Municipality? Yes No If yes, which one?_________________________________________
Do you currently serve on a County Board or Committee? Yes No If yes, which one(s)? ______________________
_____________________________________________________________________________________________________
Please list any appointed positions you currently hold in Henderson County or any municipal government _______________
_____________________________________________________________________________________________________
Place of Employment: _______________________________________ Position/Title: _______________________________
If retired, former Place of Employment and Position/Title: _____________________________________________________
Please indicate your educational background, special qualifications, related work experience, etc. _____________________
_____________________________________________________________________________________________________
Which Boards and/or Committees are you interested in? Please list in order of preference.
________________________________________________________________________ 1.
_________________________________________________________________________ 2.
_________________________________________________________________________ 3.
Note: If you are applying for the Home & Community Care Block Grant Committee, are you 60+ years of age? Yes No
If you are applying for the Nursing Home Adult Care Advisory Committee: (1) Do you or someone in your immediate family have a
Financial interest in a nursing home located in Henderson County?
Yes No (2) Is someone in your immediate family
A resident in a nursing home located in Henderson County?
Yes No
References: Please list the name and telephone number of three Henderson County Residents.
1. Name: ___________________________________ Telephone No. __________________
2. Name: ____________________________________Telephone No.__________________
3. Name: ____________________________________Telephone No.__________________
CONFLICT OF INTEREST DISCLOSURE
Full Name of Spouse (if married): __________________________________________________________________
Spouse’s Place of Employment or Business Affiliation: _________________________________________________
Spouse’s Position/Title: _________________________________________
Please list all entities (including corporations, partnerships, associations, or other private, public, and nonprofit
organizations) of which you or your spouse are an officer, director, trustee, partner or employee, or have at least a five
percent (5%) ownership interest, and describe your affiliation with such entity (if there are none, state “None”):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Do you (or your spouse, employer, or business entity with which you are at least a five percent (5%) beneficial owner or an
officer or employee) stand to have a financial interest resultant from your participation on a Henderson County Board
and/or Committee? (Financial interests could include contractual arrangements, grants, vendor/ contractual arrangements,
etc.). If your answer is yes, please describe.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
In your experience as a Board and/or Committee member, are there potential conflicts you think Henderson County should
be mindful of? ________________________________________________________________________________________
_____________________________________________________________________________________________________
By submitting this Application for Appointment, I pledge that, if appointed, I agree by my signature below that all of the
information above is complete and accurate to the best of my knowledge and I pledge to comply with the following ethics
guidelines as fully set forth in the Code of Ethics. The full text of the Code of Ethics as adopted by the Board of
Commissioners may be found by visiting Henderson County’s website (www.hendersoncountync.gov)
I. Decla
ration of Policy
The proper operation of democratic government requires that public officials and employees be independent,
impartial and responsible to the people; that governmental decisions and policy be made in proper channels of
the governmental structure; that public office not be used for personal gain; and that the public have
confidence in the integrity of its government.
In recognition of these goals, a Code of Ethics for county officials was adopted. The purpose of this policy is to
establish guidelines for ethical standards of conduct for all officials and to set forth actions that are compatible
with the best interests of the County.
II. Applicability of Ethics Policy
The provisions of this policy shall apply to all elected and appointed county officials, members of County Boards
and Committees appointed by the County Commissioners and other County employees.
III. Financial and Personal Disclosure
Any County official or employee who must officially consider any public matter involving his financial or
personal interests or those of his immediate family, shall first publicly disclose the nature and extent of such
interest and shall abstain from acting thereon unless provisions of state law require otherwise.
IV. Gifts and Favors
No official or employee shall knowingly accept any gift, whether in the form of money, thing, favor, loan or
promise, when it could reasonably be inferred that the gift was intended to influence or reward an official
action on his part. Gifts, meals, other favors of an incidental nature and of minor value (less than $100), or
legitimate political contributions shall not be included in this policy.
V. Appointment, Employment, or Contract Award of Relatives or Business Partners
Public officials of the appointing authority must disclose on the public record any person of their immediate
family related by blood or marriage or business interest who is being considered for appointment, employment,
or contract award by that authority.
____________________________________________________ _______________________________
Applicant’s Signature* Date
*By typing your name you are signing this document
Please return Application to: Terry Wilson, Clerk to the Board
1 Historic Courthouse Square, Suite 1
Hendersonville, North Carolina 28792
Telephone: (828) 697-4808 / (828) 694-5025
Office Hours: 8:30 a.m. to 5:00 p.m.
For Office Use Only:
Applicant ID ____________ Scanned Copied to BOC
Application expires (3) three years from date of Application.
Upon appointment to a Board/Committee, the information contained herein becomes a matter of public record per North Carolina
Statute 132-1
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APPLICATION FOR APPOINTMENT TO HENDERSON COUNTY BOARDS &

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Completed 19 July 2020

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