Fill - Free fillable BOARD OF COUNTY COMMISSIONERS (Lucas County) PDF form

_______________________________________________________________________________________

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: TOLEDO/LUCAS COUNTY COMMISSION ON DISABILITIES

What experience or knowledge do you have ion regards to disability culture, disability rights, or issues

relating to disability? Note any personal experience that would make you a good advocate.

Do you or an immediate member of your family have a disability?

No Yes

Have y

ou, 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.

Fill Online, Printable, Fillable, Blank BOARD OF COUNTY COMMISSIONERS (Lucas County) Form

Related forms

Fillable BOARD OF COUNTY COMMISSIONERS (Lucas County)

Fill Online, Printable, Fillable, Blank BOARD OF COUNTY COMMISSIONERS (Lucas County) Form

Related forms

First 20 documents completely FREE!