ࡱ> JLI] -bjbj\\ .26i6iX X 87,c,.&%%%%%%%$@)+%9%%PPPF%P%PP:M$,$0# ,y$ u%%0.&$R,Z,$,$P%%Z.&,X Y : STATE OF MAINE Office of the Governor Janet T. Mills Joe Boucher Governor Director, Boards and Commissions APPLICATION FOR GUBERNATORIAL APPOINTMENT Name_________________________________________________________________________ Town of Residence__________________________________ Year-Round Resident?__________ Occupation_____________________________________________________________________ Home Mailing Address ______________________________________________________________________________ Business Address ______________________________________________________________________________ Phone (work) _____________(home)______________(fax)___________e-mail______________ Please feel free to attach a sheet if not enough space is provided for your answers. A rsum that includes complete education, employment and professional history is also required. Please return this form and rsum to HYPERLINK "mailto:boardsandcommissions@maine.gov"boardsandcommissions@maine.gov. List name(s) of board and /or commissions you are interested in serving on:    Where are you currently employed? ______________________________________________________________________________ Have you ever been elected or appointed to public office (including other boards/commissions) in fb88? If yes, please list and include dates:  Please list association memberships:  Have you been or are you now a registered lobbyist? If yes, please list the principals you represent(ed) and dates:__________________________________________________________ Have you or members of your immediate family (spouse, domestic partner, child, parents, siblings) or businesses in which you or they have been an owner, officer, or employee, had any contractual or other direct dealings during the last four years with any government agency? If yes, please explain (Use a separate attachment if necessary).____________________________ ______________________________________________________________________________ Have you held or do you hold an occupational or professional license or certificate in the State of fb88 or any other state? If yes, please note the type of license/certificate and the issuing authority:______________________________________________________________________ If you are applying for a public member slot on a licensing board, have you or members of your immediate family (spouse, domestic partner, child, parent(s), siblings) been a member of this profession or associated professions? If yes, please explain:  Can you: Attend daytime meetings?____ Spend time reading materials in preparation for meetings? _____ Is there anything else you think we should know about you, your background, or experiences?   Please list three persons unrelated to you who would support your appointment: Name Occupation Address Phone    Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law, regulation, or ordinance (exclude traffic violations for which a fine or civil penalty of $150 or less was paid)? Yes____ No____ If yes, please give details:______________________________________ Optional Information: The following questions are designed to elicit information that will be used to assure that there is maximum diversity in the appointments that are made in the Administration. Please note that some boards and commissions require specific representation such as bipartisan representation or disabled representation. These questions are designed to assist the Administration in meeting such requirements. Responses by applicants are purely voluntary. Political Affiliation: _____________________ Congressional District: __________ Disabling Characteristic: __________________________________________________ Gender: n Male n Female Ethnicity: n Caucasian n African American n Hispanic n Native American n Asian/Pacific Islander n Other ___________________ ****************************************************************************** I hereby certify that %&47BDop! 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