Fillable OFFICE OF THE GOVERNOR REQUEST FOR APPOINTMENT CONSIDERATION (State of Maryland)

Fill Online, Printable, Fillable, Blank OFFICE OF THE GOVERNOR REQUEST FOR APPOINTMENT CONSIDERATION (State of Maryland) Form

Use Fill to complete blank online STATE OF MARYLAND (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

OFFICE OF THE GOVERNOR REQUEST FOR APPOINTMENT CONSIDERATION (State of Maryland)

On average this form takes 17 minutes to complete

The OFFICE OF THE GOVERNOR REQUEST FOR APPOINTMENT CONSIDERATION (State of Maryland) form is 3 pages long and contains:

  • 1 signature
  • 3 check-boxes
  • 64 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Maryland

BROWSE STATE OF MARYLAND (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
OFFICE OF THE GOVERNOR
REQUEST FOR APPOINTMENT CONSIDERATION
BIOGRAPHICAL INFORMATION FORM
Please state below, the board or commission or general subject area in which you have an interest:
Application for:
New Appointment
Reappointment
Name:
Date of Birth:
US Citizen
MD resident since ________
Race:
Gender:
(Ethnic/gender data is solely to assure diversity in representation)
Home Address:
City:
State:
Zip:
Resident County:
MD Legislative District:
MD Congressional District:
Council or
Commission District:
Occupation:
Employer:
Work Address:
City:
State:
Zip:
Phones:
(Office):
(Home):
(Cell):
(Fax):
Email Address:
Sponsoring Organization (If Any):
____________________________________________________________________________
Have you ever been a party (plaintiff or petitioner/defendant or respondent) to any civil, criminal, juvenile or administrative proceeding?
No
Yes (Specify):
Do you hold a Maryland license to practice a profession or trade?
Yes
No
If yes, specify License:
Have you ever had a license to practice a profession or trade, whether held in Maryland or another state, revoked or suspended?
No
Yes (Specify):
Are you a member, officer or director of any organization?
Yes
No
Specify Organization or Activity:
If so, are you engaged in any lobbying activities for that organization?
Yes
No
Are you a paid lobbyist for any organization?
Yes
No
If so, please specify the organization:
Do you hold, or have you held in the past, an elected or appointed office within Federal, State or
local government, or a political party?
Yes
No
Specify Office:
Specify Dates:
Have you filed all Federal and State tax returns that are now due or overdue and are all payments thereupon up to date?
Yes
No
Yes
No (Explain):
Have Federal, State or local authorities ever instituted a lien or other collection procedures against you?
No
Yes (Explain):
List the names, business addresses, and business telephone numbers of at least 2 individuals who are familiar with your professional
qualifications and who have known you for more than the last five years:
1.
2.
PLEASE EXPLAIN WHY YOU WANT TO BE A MEMBER OF THE BOARD/COMMISSION.
Please attach a resume that includes information concerning your academic background, work experience and professional, political and
civic organization affiliations. If a resume is not available, please supply requested information in spaces provided below.
ACADEMIC BACKGROUND:
WORK EXPERIENCE:
ORGANIZATIONAL AFFILIATIONS:
I certify that, to the best of my knowledge and belief, all the information contained in and attached to this questionnaire is true, correct and
complete. I understand and agree that I am required to notify the Office of the Governor in writing if any of the information contained in or
attached to this questionnaire changes.
Signature of applicant: _______________________________________________________________ Date: ____________________
Completed forms may be returned to:
Anna Lieberman, Administrator, Office of Appointment and Executive Nominations
201 W. Preston Street, Baltimore, MD 21201
Phone: (410) 767-4049 Fax: (410) 333-7687 Email: alieberman@dhmh.state.md.us
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

OFFICE OF THE GOVERNOR REQUEST FOR APPOINTMENT CONSIDERATION (State of Maryland)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document