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Shelby County Board of Commissioners Application For Appointment to Elected Office
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Steps
1.
Applicant
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This section is incomplete
2.
Professional Background & Experience
This section is complete
This section is incomplete
3.
Personal Information
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This section is incomplete
4.
Education
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5.
Achievements
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6.
Authorization for Release of Information
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Applicant
Application for Appointment to Elected Office
First Name
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Last Name
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Office Address
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City
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State
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Zip
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Office Phone
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Facsimile
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Email Address
*
Home Address
Street Number
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Street Name
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Street Type
Apt #
City
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State
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Zip
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Home Phone
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Cellular Phone
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Professional Background & Experience
Professional Background & Experience
1. Indicate your Present Employment. What is the Principal business of the business?
2. List your prior professional or business employment since completion of high school and lasting more than twelve months with dates and names of employers.
3. Describe any experience not stated above that you would like to bring to the attention of the Commission.
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Personal Information
4. How long have you lived continuously in Shelby County?
5. State the county in which you are registered to vote.
6. List all states in which you have lived in the past 20 years and the dates you lived in each state, including all periods in which you resided in a state more than 50% of the time for a period of at least 12 months.
7. State your age, date and place of birth.
8. a) Drivers License No.
b) Election Commission Voter Registration No.
9. Family Status
a) State the full name and present address of your spouse.
b) State your spouse's occupation and place of employment.
c) If you have children, state their name(s), age(s), address(es) and present occupation(s).
10. Military Service
a) Branch of Service
b) Service Number
c) Dates of active duty
d) Rank/rate at separation
e) Decorations, honors, or achievements
f) Was your discharge other than honorable? If so, explain.
11. a) Have you ever pled guilty or been convicted or are you now on diversion for violation of any law, regulation or ordinance?
Yes
No
b) Give date, court, charge and disposition.
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12. To your knowledge, are you now under federal, state or local investigation for possible violation of a criminal statute? If so, give details.
13. Have you ever been interviewed by any federal, state or local law enforcement agency for any reason other than minor traffic violation? If so, give details.
14. If you have been disciplined or cited for breach of ethics or unprofessional conduct by a court, administrative agency, disciplinary committee, or other professional group, give details.
15. Has within the last five years, has a tax lien or other collection procedure been instituted against you by federal, state or local authorities or creditors? If so, give details.
16. a) Are you currently a party in any legal proceedings?
Yes
No
b) If so, give details including the date, court and docket number, and disposition. Provide a brief description of the case.
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17. a) Are you now an officer or director of any business organization, or are you otherwise engaged in the management of any business enterprise?
Yes
No
b) If so, give details, including the name of the enterprise, the nature of the business, the title or other description of your position, the nature of your duties, and the terms of your service.
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c) Do you consider continuation of such business involvement to be a conflict of interest?
18. If your income is not wholly derived from your present employment as noted in #1 above, specify in detail the other sources of your income and the approximate percentage of your total income each source represents.
19. List all organizations to which you have belonged within the last ten years, including professional associations, civic, charitable, religious, educational, social and fraternal organizations. Give the titles and dates of any offices which you have held in such organizations.
20. a) Have you within the past ten years belonged to any organization, association, club or society which limits its membership to those of any particular race, religion or gender? Do not include in your answer those organizations specifically formed for a religious purpose, such as churches or synagogues.
b) If so, list such organizations and describe the basis of the membership limitation.
c) If it is not your intention to resign from such organization(s) and withdraw from any participation in their activities should you be selected for the position for which you are applying, state your reasons.
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Education
21. List each college, law school, and other graduate school which you have attended, including dates of attendance, degree awarded and major.
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Achievements
22. List honors, prizes, awards, or other forms of recognition which you have received since your graduation or college which are directly related to professional accomplishments.
23. List presentations you have made to groups and organizations within the past five years.
24. List any public office you have held or for which you have been candidate or applicant. Include the date, the position, and whether the position was elective or appointive.
25. Describe any experience you have had with legislative or executive branches of government other than as an elected or appointed official.
26. Describe life experiences, personal involvements, or talents that you have that you feel will be of assistance to the Commission in evaluating and understanding your candidacy for this elected position. (150 words or less).
27. Read, and if you agree to the provisions, sign the following:
I have read the foregoing questions and have answered them in good faith and as completely as my records and recollections permit. I hereby agree to be considered for appointment to the office of
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, and if appointed by the Shelby County Board of Commissioners, agree to serve that office.
In the event any material changes occur between the time this application is filed and the public hearing, I hereby agree to file an amended application with the Board of Commissioners for distribution to the commission members.
I understand that the information provided in this application shall be open to inspection upon filing with the office of the Shelby County Board of Commissioners and that the Commission may publicize the names of persons who apply for appointment and the names of those persons the Commission considers for the vacancy in question.
Printed Name
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Date
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Date
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Authorization for Release of Information
I,
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, do hereby authorize the Shelby County Sheriff and/or the Shelby County Attorney and any and all agents or persons authorized by it, to conduct a full review and disclosure of all records concerning myself, whether said records are public, private, or confidential in nature. The intent of this authorization is to give my consent for full and complete disclosure of records of all criminal charges, with the exception of minor traffic offenses, whether disposed of or pending, and any outstanding warrants in accordance with Rule 34 or the Shelby County Board of Commissioners' Permanent Rules of Order.
I also certify that any persons who may furnish such information concerning me shall not be held accountable for giving this information, and I do hereby release said persons from any and all liability which may be incurred as a result of furnishing such information. I further specifically release the Shelby County Sheriff and/or the Shelby County Attorney and/or the Shelby County Board of Commissioners from any and all liability which might otherwise be incurred as a result of collecting or receiving such information.
I have read and fully understand the contents of this Authorization for Release of Information.
Print Full Name of Applicant (include maiden)
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Address
*
Phone
*
Date of Birth
*
Date of Birth
*
Drivers License #
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Date
*
Date
*
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