Fillable Affidavit of Qualifications for Wisconsin Technical College District (Chippewa Valley Technical College)

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Affidavit of Qualifications for Wisconsin Technical College District (Chippewa Valley Technical College)

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TECHNICAL
COLLEGE
SYSTEM
Affidavit of Qualifications for
Wisconsin Technical College District Board Membership
Wisconsin Statutes establish requirements for the process of selecting members who will
serve on the district boards of the 16 local colleges that make up the Wisconsin Technical
College System. Applicants must submit this affidavit if applying for any of the 16
WTCS Boards, except Milwaukee Area Technical College (MATC).
Do not use this affidavit if you are seeking to serve on the MATC Board. Those applying
to serve on the MATC Board must apply using the specific MATC affidavit form
available at Documents for District Board Applicants.
To become a candidate who is considered to serve on the board of a Wisconsin
Technical College you must:
1. Submit a properly completed, signed and notarized affidavit of your qualifications
to the district board appointment committee by the deadline established in the
published announcement requesting applications;
2. Attend a district board appointment committee public hearing in person and be
interviewed; and
3. Submit at least two letters of reference supporting your candidacy.
If approved to serve on a district board, you are required to abide by the State of
Wisconsin Code of Ethics and must file annual financial disclosure statements with the
State of Wisconsin Ethics Commission.
Board members serve without salary or per diem. Actual and necessary expenses
incurred in the performance of their duties are reimbursed.
Each year, three members are appointed to serve a three-year term that begins on July 1.
According to Wisconsin Statutes, each of the 15 boards (excluding MATC) must include
the following nine members:
• 3 additional members;
• 2 employers;
• 2 employees;
• 1 school district administrator; and
• 1 elected official.
Revised December 2019
Page 1 of 5
Identification and Residency
Eligible candidates must reside in the technical college district for which they seeking to
be appointed as a board member.
I, , reside at
(Name of Candidate – please type or print)
, ,
(Street) (City, Village, Town) (Zip Code)
( ) .
(County) (Area Code / Phone Number)
I am a resident of the Technical College District and I meet the
(WTCS College Name)
requirements for serving on a district board as outlined in s. 38.08, Wis. Stats.
Minority Status: You will be considered a minority if you indicate any of the following
categories:
☐ American Indian or Alaskan Native
☐ Black/African American
☐ Asian
☐ Native Hawaiian and Other Pacific Islander
☐ Hispanic
☐ Two or More Races
Gender:
☐ Male
☐ Female
Board Membership Category
Please identify all board membership categories for which you may qualify; many people
qualify for membership in more than one category. For instance, you automatically
qualify as an additional member for the college where you live. If you are working, you
might also qualify as an employer or employee member.
Do not use this form if you are applying for membership on the Milwaukee Area
Technical College District Board. Instead, applicants for the MATC Board must use the
specific MATC affidavit form.
Revised December 2019
Page 2 of 5
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☐
☐
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Check all
that apply:
Additional: All residents of a technical college district are eligible to serve as an
additional member for that college.
Employer: To qualify as an employer, you must receive earnings as payment for your
service and possess the power to hire, transfer, suspend, layoff, recall, promote,
discharge, assign, reward or discipline other employees or adjust employee
grievances or effectively recommend such action if in connection with the exercise of
such power the person exercises independent judgment in relation to the power.
Employer does not include a person acting in the capacity of officer or agent of a
labor organization. At the time of their appointment, employers also must be actively
engaged in business and employ others.
Check all of the actions that are part of your regular responsibilities as an employer:
☐ Assign ☐ Adjust Grievances
☐ Discharge ☐ Discipline
☐ Hire ☐ Layoff
☐ Promote ☐ Recall
☐ Reward ☐ Suspend
☐ Transfer
Employer and Your Position:
(Company/Organization/Name)
(Title)
(Street)
(City, State, Zip Code)
(Business Phone Number)
Date appointed to current position:
Employee: You receive payment for work performed but do not qualify as an
employer using the definition described above. An officer or agent of a labor
organization automatically qualifies as an employee.
Employer Name Title/Position
Revised December 2019
Page 3 of 5
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☐
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administrator category if, as defined in s. 115.001 (8), Wis. Stats., you are a school
district superintendent, supervising principal, or other person who acts as the
administrative head of a school district.
Elected Official: You are considered an applicant in the elected official category if,
as defined in s. 5.02, Wis. Stats., you are a state or local elected official.
☐
City Council
☐
State Legislature
☐
Common Council
☐
Town Board
☐
County Board
☐
Town Clerk
☐
School Board
☐
Village Board
☐
Sheriff
☐
Additional Information
With your affidavit, please submit up to a one page single-spaced statement describing
your reasons for seeking an appointment to the board of your local college.
If you are applying as an employer or employee member and your job is located outside
the geographic boundaries of the district in which you reside, your statement should
include how your company serves the population of the technical college district for
which you are seeking to serve on the board.
You also may attach a resume or additional sheets to describe your:
• Employment or work history;
• Membership and positions held in business, professional, or civic groups and
labor organizations;
• Educational background and degrees conferred;
• Honors, awards, or citations; and
• Any other information you believe would be helpful for the appointment
committee.
Revised December 2019
Page 4 of 5
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Your affidavit is not complete unless it is signed and notarized:
I declare the information I have included in this affidavit is accurate to the best of
my knowledge and is submitted pursuant to Chapter 38.08 and 38.10, Wis. Stats.,
and Chapter TCS 2, Wis. Adm. Code. I agree that I will provide any additional
requested information or respond to questions from the local district board
appointment committee or the Wisconsin Technical College System Board as needed
to verify my qualifications for the board member position I am seeking.
Candidate Signature
Candidate email address:
Notarized per s. 706.07(8), Wis. Stats.:
State of
County of
Signed or attested before me on ( ) by ( ).
Date Name of Applicant
Signature of Notarial Officer
(Seal, if any)
☐
My commission expires .
☐
My commission is permanent.
PRINT
RESET
Revised December 2019
Page 5 of 5
PRINT
RESET
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Affidavit of Qualifications for Wisconsin Technical College District (Chippewa Valley Technical College)

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Completed 9 October 2020

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