Fillable TEXAS HIGHER EDUCATION COORDINATING BOARD (THECB) (Sam Houston State University)

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TEXAS HIGHER EDUCATION COORDINATING BOARD (THECB) (Sam Houston State University)

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TEXAS HIGHER EDUCATION COORDINATING BOARD (THECB)
NON-VOTING STUDENT REPRESENTATIVE
QUALIFICATIONS
• Term: June 1, 2020 – May 31, 2021
• Academics (to qualify and, if selected, must maintain for the duration of the term):
o Undergraduate or Graduate student enrolled in a public institution of higher education
o Good academic standing
o Overall GPA of at least 2.5
o Enrollment at public institution of higher education for duration of term
• Other:
o Have a state-wide perspective of higher education
o Strong drive and self-motivation to contribute to the progress of higher education
o Commit to board related responsibilities to attend no less than 3 out of 4:
Quarterly board meetings
THECB committee meetings as scheduled
APPLICATION PROCESS
• Due Date: Friday, December 6, 2019
• Submit To: SHSU Vice President for Student Affairs Office (VPSA)
Student Affairs Annex, 919 Bearkat Boulevard or Campus Box 2237
• Application Packet (single-sided):
1. Complete all forms directly following this page (print out the completed forms and sign)
Include a professional picture either in the designated place within the application or
attach to your application so we may assist. The picture must be able to fit within the
space provided.
2. Resume
3. Three letters of recommendation (one from each of the following)
♦ The College Dean of your major
(Example: Accounting major = Dean, College of Business Administration)
♦ Faculty Member
♦ Faculty or Staff Member
4. Unofficial Transcript – the VPSA Office will print your unofficial transcript and attach to your
application documents.
Application for Coordinating Board
Student Representative
Please at
tach a resume and an unofficial transcript when you submit your application.
*If additional room is needed, please attach a separate document.
Name:
Institution:
Graduation Date:
GPA:
Mailing Address:
Phone Number:
E-mail:
Please describe an issue related to higher education that you are most interested in and why.
Limit to 150 words*.
Please explain how you would help your fellow college students by serving.
Limit to 150 words*.
Major(s):
Revised 6/19 1
GOVERNOR GREG ABBOTT
OFFICE OF THE GOVERNOR
APPOINTMENT APPLICATION
1. Personal Information 2. Photograph
Full Legal Name
(Photo may be attached
as a separate
attachment/document)
Preferred Name
Spouse’s Name
Physical Home Address
City, State Zip ,
Mailing Address
City, State Zip ,
County
Work Telephone
- -
Home Telephone
- -
Cellular
- -
Preferred E-mail Address
Secondary E-Mail Address (if applicable)
3. State Board(s), Commission(s), Task Force(s) or Areas of Interest to You:
The list of all entities to which the Governor makes appointments and areas of interest
may be found at:
https://gov.texas.gov/organization/appointments/positions. If you are
applying for a judicial or district attorney appointment, please list the position below.
4. Employment Information
Employer
Employer’s Address
Present Job Title
Profession
Present Job Description
Revised 6/19 2
Name
5. Education/Training
Type of School Name and Location of School
Year
Graduated
Degree and
Field of Study
High School
Undergraduate
Graduate
Other
6. Employment History
Employer
Position
Dates
Location
7. References
8. Professional Memberships (including any state bar memberships)
Organization
Title/Position
Current/Former
9. Volunteer Participation
Organization
Title/Position
Current/Former
10. Military Service
Are you or have you ever been a member of the Armed Forces of the United States: Yes No
Branch
Dates of Service
Type of Discharge
Name
Employer
City
Telephone
Relationship
- -
- -
- -
- -
- -
Revised 6/19 3
Name
11. Social Media Information
Do you use, or have you ever used, any of the following? If “yes,” provide additional information.
Facebook Yes No
Username
Twitter Yes No
Handle @
Instagram Yes No
Username
LinkedIn Yes No
Profile
12. Spouse Information This Section Not Applicable
Spouse’s Employer
Job Title/Position
Does your spouse conduct any business with or before the
Texas Legislature or any other state entity? Yes No
If yes, please list agencies:
13. Miscellaneous Information
Note: “Material interest” is defined as (a) serving on the governing board of directors or (b) a ten (10)
percent or greater ownership. This does not apply to any mutual funds in which you do not exercise
authority in investment decisions.
Have you filed federal income tax returns for the past five (5) years? If no, give details.
Yes No
Have you ever defaulted on a personal, business or student loan? If yes, give details.
Yes No
Type of Loan
Date
Details
Are you, your spouse, or any company in which you have a material interest currently
delinquent in any local, state or federal taxes? If yes, give details.
Yes No
Have you, your spouse, or any company in which you have a material interest or of which
you have been an officer or principal been involved in any bankruptcy proceeding? If yes,
give details including dates.
Yes No
Do you currently serve, or have you ever served, on any local, state or federal government
board, commission or committee or in any elected or appointed office?
Yes No
Entity Position Dates
Compensated
(Y/N)
Reimbursed
(Y/N)
Revised 6/19 4
Name
13. Miscellaneous Information (Continued)
Are you or your spouse related to a local, state, or federal public official?
Yes No
Name of Official and Title
Relationship
Do you or your spouse have any material interest in, or are either of you employed by, any
company that does business with or receives funds from the State of Texas?
If yes, give full name and details:
Yes No
Name of Company
Details
Are you or your spouse an officer, director, employee or paid
consultant of a trade association? Yes
No
If yes, please list association and position:
Self
Spouse
Have you or your spouse ever been registered as a lobbyist or received compensation to
represent someone before a local, state, or federal government?
Yes No
Self or
Spouse
Entity Represented
Entity Lobbied
Dates
Have you, your spouse, or any company in which you or your spouse have a material
interest been party to litigation? If yes, give details.
Yes No
In the last five years, have you, or any company in which you have a material interest, been
licensed by a Texas state agency? If yes, give details.
Yes No
Agency
Type of License
License #
Expiration
Have you ever been delinquent in child support payments? If yes, give details.
Yes No
Not
Applicable
Revised 6/19 5
13. Miscellaneous Information (Continued)
Have you ever been convicted in a criminal proceeding (excluding traffic violations), placed
on probation, required to perform community service, or had a criminal proceeding disposed
of by pre-trial diversion, deferred prosecution, deferred adjudication, or some similar
proceeding?
If yes, list the charge, the date of the offense, the city and/or county and state in which it
allegedly occurred, and the disposition thereof.
Yes No
Name
To the best of your knowledge, has any federal, state or local law enforcement or regulatory
agency (on behalf of itself or any other person or entity) filed or investigated any grievance or
complaint against you, your spouse, or an entity in which you have a material interest? If
yes, give details and disposition (investigated, dismissed, reprimanded)
Yes No
Agency
Date
Details and Disposition
To the best of your knowledge, have you, your spouse, or any company in which you have a
material interest been investigated, reprimanded, fined or suspended from doing business
with any state or federal agency? If yes, give details and disposition (investigated,
reprimanded, fined, suspended)
Yes No
Agency
Date
Details and Disposition
Revised 6/19 6
14. Certification
Full Legal Name
Date of Birth / /
Texas Driver License or DPS ID#
Are you a U.S. Citizen? Yes No
Place of Birth
Date of naturalization (if not a citizen upon birth) / /
Ethnicity: (optional; check all that apply)
White African American Native American
Hispanic Asian American Native Hawaiian or Other Pacific Islander Two or More Races Other
Notes:
• Appointment to a Board or Commission may require the annual filing of
a Personal Financial Statement (PFS) Form with the Texas Ethics
Commission.
• A resume must be attached in order for this application to be
considered complete.
• All current and former attorneys must also complete the State Bar and
Judicial Conduct Release Form.
• Judicial and district attorney candidates must also complete the
Judicial Questionnaire and the State Bar and Judicial Conduct Release
From.
• Any information provided on the application or attached may be subject
to the Texas Public Information Act. This means that an individual
requesting copies of the information in your file may be provided
access to that information.
CERTIFICATION OF APPLICANT
I hereby certify that the foregoing and any attached statements are true, accurate
and complete. I agree that any misstatement, misrepresentation, or omission of a
fact may result in my disqualification for appointment. I assign and hereby give
the Office of the Governor full authority to conduct background investigations
pertinent to this application. I specifically authorize the Texas Department of
Public Safety to conduct a background investigation and to disclose the results of
that investigation to the Governor or his authorized representative.
__________________________
Applicant’s Signature
__________________________
Submit by ONE of the following: Date
Appointments Staff (512) 475-2576 fax
Office of the Governor
PO Box 12428
Austin, Texas 78711
ServingTexas@gov.texas.gov (with signed signature page)
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TEXAS HIGHER EDUCATION COORDINATING BOARD (THECB) (Sam Houston State University)

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Completed 26 August 2020

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