Fillable Ethics Application Fillable - Committee Application DMWEST_16294013(2)

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Ethics Application Fillable - Committee Application DMWEST_16294013(2)

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1
CITY OF PHOENIX ETHICS COMMISSION
APPLICATION FOR NOMINATION TO COMMISSION
APPLICATION INSTRUCTIONS
Thank you for your interest to serve on the City of Phoenix Ethics Commission. Please read these
instructions carefully and submit any questions about the application or the nomination process to
ethics.application@phoenix.gov
.
1. This application is a public record. As a public record, information denoted as “Public Information” (Section I) is
available for public inspection and may be posted on the City of Phoenix website. Public Information includes the
applicant’s name, occupation, employer, relevant work history, other responses contained in Section I, and any other
information that is specifically authorized for release by the source of the information. Information denoted as “Personal
Information” (Section II) is confidential and is not available for public inspection. Personal Information includes the
applicant’s home address, applicant’s family information, other information provided in Section II, information provided
by third parties such as references, notes of Board members that are generated for personal use, and any information
obtained by or submitted to the Board that is made confidential by other provisions of law. Completed applications,
including the confidential portion, are forwarded to the City Council upon nomination by the Board.
2. Applicants must download or request the application form in electronic format. To download the form, go to the Boards
and Commissions website at http://phoenix.gov/phxd/bdcomm/index.jsp . To request the form, send your request to:
ethics.application@phoenix.gov.
3. The electronic form is a fillable PDF, which may be completed using Adobe Acrobat Reader. All information should be
typewritten. Some questions permit a limited response. If additional space is need, attachments may be added to the
application.
4. Completely answer all questions. If a question does not apply, write "Not applicable" in the space provided. If
information is not available, write "Not available" and state the reason(s) the information is not available.
5. You may reveal contact information for any individual in the confidential section of this application.
6. The application must be filed with the City of Phoenix Judicial Selection Advisory Board. You may file an application
electronically or by hard copy. To file an electronic application, email the completed application to
ethics.application@phoenix.gov. To file a hard copy, applications may be completed, printed, and either mailed or
delivered to the following address: City of Phoenix Judicial Selection Advisory Board, Attn: City Clerk, 200 W.
Washington St., 15th Floor, Phoenix, AZ 85003-1611.
A FIRST REVIEW OF APPLICANTS WILL BE HELD ON MONDAY, APRIL 16, 2018. COMPLETE
APPLICATIONS INCLUDE AN ELECTRONIC OR HARD COPY APPLICATION AND ALL
SUPPORTING INFORMATION.
The Board cannot be responsible for applications not received; if the U.S. mail is used, applications should be sent by
registered or certified mail, return receipt requested. If you would like acknowledgment of receipt of the application,
enclose a self-addressed, stamped envelope.
INSTRUCTIONS FOR LETTERS OF REFERENCE
An applicant may solicit letters of reference that assess the applicant’s skills, expertise, ethics, and any other characteristics
relevant to an applicant’s qualifications to serve on the Commission. Although the Board has not established a limit, "more" is
not necessarily "better." Applicants are encouraged to solicit substantive letters of reference that provide sufficient insight into
the applicant’s potential to serve as an outstanding Commission member.
2
Applicant lette
rs of reference should be sent to the Board in care of City of Phoenix Judicial Selection Advisory Board,
Attn: City Clerk, 200 W. Washington St., 15th Floor, Phoenix, AZ 85003-1611, no later than three business days
before the screening and/or interview meetings. All letters timely submitted to that address will be forwarded to the Board.
PERSONAL CONTACT WITH BOARD
Applicants should not personally contact Board members regarding their application or the nomination process from the time
his or her application is submitted until the individual’s application is no longer under consideration. Board members cannot
individually interview applicants or commit in advance to vote for any applicant.
INSTRUCTIONS FOR INTERVIEWS
Subject to applicable rules, applicants are interviewed in public session. In fairness to other applicants, an applicant should not
attend earlier scheduled interviews of other applicants or otherwise seek out or accept information about the content of such
interviews.
SUMMARY OF THE NOMINATION PROCESS
1. Application Period: The Board announces the vacancy. The press release announcing the vacancy advises where
application forms can be obtained and the deadline for submitting applications.
2. Public Notice: Information of the date, time, and location of the Board’s screening meeting are made by public notice.
3. Screening Meeting: At the screening meeting the Board reviews all applications received and the results of any
investigation conducted by Board members. Voting to determine the applicants to be interviewed is conducted in public
session.
4. Notification to Applicants: Applicants selected for interview are notified by letter of the date, time and location of
the interviews. Applicants not selected for interview are notified by letter.
5. Public Notice: The Board announces the names of the applicants to be interviewed and invites oral or written public
comment regarding their qualifications.
6. Investigation: Further investigation of the applicants to be interviewed is conducted. The credit, criminal, and
professional discipline histories of the applicants are requested, and the results are given to the Board.
7. Interviews: Subject to applicable rules, the applicant is interviewed in public session. After all the interviews are
completed the Board discusses the relative qualifications of all the applicants. Voting to determine the nominees to be
submitted to the City Council is conducted in public session.
8. Nominations: Further investigation of the applicants to be interviewed is conducted. Applicants authorize all
references, employers, credit reporting agencies, business and professional associations to release to the Board any
information requested by the Board in connection with their application. The Board may also seek comments from the
community.
9. Public Notice: The names of the nominees are announced. Each nominee's political party registration is included in the
announcement.
10. Records Retention: The Board members’ personal notes are not public information. The original application
information and all documents received with respect to the application are maintained and destroyed pursuant the City of
Phoenix Records Retention Schedule. At an applicant’s request and expense, the original application, the .pdf version,
and any supplemental material submitted by the applicant may be returned to the applicant during the applicable retention
period. Otherwise, after the applicable retention period, any applications, .pdf files, and supplemental materials retained
by the Board shall be destroyed and deleted.
3
CITY OF PHOENIX ETHICS COMMISSION
APPLICATION FOR NOMINATION TO COMMISSION
SECTION I—PUBLIC INFORMATION
FULL NAME:
CONTACT ADDRESS (INCLUDING ZIP):
CONTACT EMAIL:
CONTACT PHONE:
IS YOUR CONTACT INFORMATION: Business OR Personal
CITY COUNCIL DISTRICT:
EMPLOYER:
TITLE:
EMPLOYER ADDRESS (INCLUDING ZIP):
1. EMPLOYMENT HISTORY.
Please provide a list of employers, including any work done as a volunteer, during the last 10 years. For each employer list
the job title and address along with the name, phone number, and/or email address for your supervisor. Attach additional
sheets as necessary.
2. EDUCATION.
Please list all post-high school education, including the name of the educational institution, years of attendance, and degree
obt
ained.
4
3. PR
OFESSIONAL AND/OR COMMUNITY OR PUBLIC SERVICE ACTIVITIES. Include date(s) of
service and, if applicable, title of office(s) held.
4. POLITICAL ACTIVITIES.
Please provide a list of any political activities that you have engaged in over the past 10 years. Attach additional sheets a
s
n
ecessary.
5. At any time within the last 10 years have you been or are you currently a registered lobbyist?
Yes
OR No If yes, please describe.
6. Is there any possible conflict of interest or other matter that prevents you from the fair and impartial discharge
of your duties as a member of the City of Phoenix Ethics Commission?
Yes
OR No If yes, please describe.
7. Are you a relative of a City of Phoenix employee or Phoenix elected official?
Yes
OR No If yes, please describe.
5
8. Do you have a substantial business interests with the City of Phoenix?
Yes
OR No If yes, please describe.
9. STATEMENT OF INTEREST.
In 500 words or less, please state why you are interested in serving on the City of Phoenix Ethics Commission. Attac
h
ad
ditional sheets as needed.
6
AFFIRMATION OF ELIGIBILITY
1. Do you c
urrently reside in Phoenix, Arizona? Yes OR No
2. Are you currently registered to vote in Arizona? Yes OR No
3. Please identify your current political party affiliation:
Democrat
Republican
Unaffiliated
Other: ______________________________________
4. Have you been registered to vote with the same political party for a minimum of five years from the date of this
application? Yes OR No
5. Are
you currently an elected official, precinct committee person of a political party, or City of Phoenix
employee? Yes OR No
OPTIONAL SECTION
The City of Phoenix strives for diversity among board, committee, and commission members. In this optional section, please
provide us with information to help us evaluate our progress in achieving this goal.
RACE/ETHNICITY
(Select all that apply)
GENDER
White (Non-Hispanic)
Male
Asian (Non-Hispanic) Female
Hispanic Decline to State
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
Black (Non-Hispanic)
Other
Decline to State
REQUIRED SIGNATURE
Under penalty of perjury, I certify the information contained in this application is t
rue, complete, and correct to the best of
my knowledge. I authorize investigation of all information in this application and considered by the Board for possible
appointment to the Ethics Commission. I further authorize all references to give the Board any and all information
concerning my qualifications and any pertinent information they may have, personal or otherwise, and release all parties
from all liability for any damages that may result from furnishing this information to the Board. As a candidate for
appointment to the City of Phoenix Ethics Commission, I understand that I must give truthful and accurate information as
requested during the review process. I understand this application and supporting information may be filed electronically or
by hard copy in a format approved by the Board. If filed electronically, I understand the Board may require additional
information by written or printed copy. I acknowledge and agree appointment to the Ethics Commission is contingent upon
the results obtained through a background check and screening.
SIGNATURE: /S/ ____________________________________________________ DATE: _____________________
Note: Typing your name acts as your signature.
7
SECTION II--PERSONAL INFORMATION
FULL NAME:
HOME ADDRESS (INCLUDING ZIP):
HOME EMAIL (IF DIFFERENT FROM CONTACT):
HOME PHONE (IF DIFFERENT FROM CONTACT):
1. PLEASE LIST THREE PERSONAL REFERENCES (NOT RELATED TO YOU BY BLOOD OR MARRIAGE):
Name: ____________________________________________________________________________________________
Phone: ___________________________________________ Email: __________________________________________
Relationship: _______________________________________________________________________________________
Name: ____________________________________________________________________________________________
Phone: ___________________________________________ Email: __________________________________________
Relationship: _______________________________________________________________________________________
Name: ____________________________________________________________________________________________
Phone: ___________________________________________ Email: __________________________________________
Relationship: _______________________________________________________________________________________
2. PLEASE LIST THREE PROFESSIONAL REFERENCES (NOT RELATED TO YOU BY BLOOD OR MARRIAGE):
Name: _________________________________________________________________________________________________
Employer: ______________________________________________________________________________________________
Phone: ______________________________________________ Email: ____________________________________________
Relationship: ____________________________________________________________________________________________
Name: _________________________________________________________________________________________________
Employer: ______________________________________________________________________________________________
Phone: ______________________________________________ Email: ____________________________________________
Relationship: ___________________________________________________________________________________________
Name: _________________________________________________________________________________________________
Employer: ______________________________________________________________________________________________
Phone: ______________________________________________ Email: ____________________________________________
Relationship: ____________________________________________________________________________________________
8
3. To your knowledge, have any charges of professional misconduct ever been filed against you?
Yes
OR No If yes, please describe.
4. To your knowledge, have any formal charges of a criminal misdemeanor or felony ever been charged
against you after you turned 18 years of age?
Yes
OR No If yes, please describe.
REQUIRED SIGNATURE
Under penalty of perjury, I certify the information contained in this application is true, complete, and correct to the best
of my knowledge. I authorize investigation of all information in this application and considered by the Board for
possible appointment to the Ethics Commission. I further authorize all references to give the Board any and all
information concerning my qualifications and any pertinent information they may have, personal or otherwise, and release
all parties from all liability for any damages that may result from furnishing this information to the Board. As a candidate
for appointment to the City of Phoenix Ethics Commission, I understand that I must give truthful and accurate information
as requested during the review process. I understand this application and supporting information may be filed electronically
or by hard copy in a format approved by the Board. If filed electronically, I understand the Board may require additional
information by written or printed copy. I acknowledge and agree appointment to the Ethics Commission is contingent upon
the results obtained through a background check and screening.
SIGNATURE: /S/ ___________________________________________________ DATE: _____________________
Note: Typing your name acts as your signature.
END OF APPLICATION
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Completed 12 July 2020

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