Fillable BOARD OF COUNTY COMMISSIONERS LUCAS COUNTY, OHIO (Lucas County)

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BOARD OF COUNTY COMMISSIONERS LUCAS COUNTY, OHIO (Lucas County)

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BROWSE LUCAS COUNTY (OH) FORMS

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BOARD OF COUNTY COMMISSIONERS
LUCAS COUNTY, OHIO
APPLICATION FOR A PUBLIC VOLUNTEER
COMMITTEE, COMMISSION, BOARD OR AGENCY APPOINTMENT
ONE GOVERNMENT CENTER, SUITE 800
TOLEDO, OHIO 43604
NAME OF APPLICANT:_______________________________________________________
First Middle Last
ADDRESS:___________________________________________________________________
Street City/State Zip Code
TELEPHONE:________________________________________________________________
Work Fax Home
EMAIL ADDRESS:________________________________________________________________________
APPOINTMENT APPLYING FOR:______________________________________________
Have you, your spouse, or any of your children under the age of 18 made a contribution to a Lucas County
Commissioner’s Campaign fund within the last five years? No Yes
Have you, a business in which you have an ownership interest, your spouse, or any immediate family
member, received a contract for goods or services within the last 5 years from the Board or Commission to
which you are seeking appointment? No Yes
If yes, please disclose the nature, duration and amount of the contract.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Are you related to any current employee of Lucas County: No Yes
If yes, give name and position _____________________________________________________
Are you related to any other member of the committee, commission, board or agency for which you are
applying? No Yes
Are you related to any employee of the committee, commission, board or agency for which you are
applying? No Yes
Do you serve on any other public or not-for-profit boards? No Yes
If yes, please identify_____________________________________________________________
_____________________________________________________________________________________
Are you a defendant or plaintiff in any pending civil law suits that could impact your service on this
public board? No Yes
If yes, please identify_____________________________________________________________
_____________________________________________________________________________________
Have you ever been convicted of a violation of any law, other than minor traffic offenses?
No Yes
If yes, please provide details:
______________________________________________________________________
______________________________________________________________________
If you are responsible for child support obligations, is your obligation current?
No Yes Does Not Apply
EDUCATION:
High School ___________________________________Date of Graduation________________________
Post-High School Education______________________________________________________________
_____________________________________________________________________________________
MILITARY HISTORY:
Branch of Service______________________________________________________________________
Discharge Date_______________ Type of Discharge__________________________________________
Highest Rank________________________________________
EMPLOYMENT HISTORY:
Present or last employer_________________________________________________________________
Your title/duties________________________________________________________________________
_____________________________________________________________________________________
Dates of Employment___________________________________to______________________________
Previous employment (list employers, position, dates of employment)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
REFERENCE:
(List three persons not related to you who you have definite personal knowledge of your qualifications for
this position)
Name Address Telephone
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
STATEMENT:
Please provide a brief statement as to why you feel you are qualified for this appointment. If you are
seeking re-appointment, please indicate what your contributions have been to the
committee/commission during the time of your service. For re-appointment, please state your
meeting attendance history.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please include any other information here that you feel would be of importance to the Commissioners in
the selection process.
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you aware of any circumstances that exist or could exist that would create a conflict of interest or the
appearance of a conflict of interest if you are appointed to this board? No Yes
If yes, please explain_____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I certify that the statements made by me in this application are true, complete, and correct to the best of
my knowledge and belief and are made in good faith. I understand that any false statements will void this
application and any actions based on it.
SIGNATURE OF APPLICANT___________________________________DATE__________________
Please submit a detailed resume with this form and return to Lucas County Deputy Clerk Steven
Spitler at sspitler@co.lucas.oh.us or One Government Center, Suite 800, Toledo, Ohio 43604.
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BOARD OF COUNTY COMMISSIONERS LUCAS COUNTY, OHIO (Lucas County)

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Completed 13 February 2021

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