ࡱ> 8:7 YbjbjOHOH :*-"c-"cY  LUUUUU0001333333$< W00000WUUl0 UU101UPT&qAb:0, P  80000000WW 0000000 000000000 : LEGISLATIVE STAFF QUESTIONNAIRE FOR GUBERNATORIAL NOMINEES NAME: HOME ADDRESS: HOME PHONE: BUSINESS ADDRESS: POSITION TO WHICH NOMINATED: IS THIS A REAPPOINTMENT? IF YES, LENGTH OF PREVIOUS SERVICE: EDUCATIONAL BACKGROUND High School: College: Graduate Work, if any: Special Training: PROFESSIONAL BACKGROUND Present Employment: How Long? Contact Person for Reference: Phone: Prior Employment: How Long? Contact Person for Reference: Phone: Page 2 PROFESSIONAL BACKGROUND (Continued): Prior Employment: How Long? Contact Person for Reference: Phone: COMMUNITY SERVICE BACKGROUND: Civic: Church (optional): Political: Other: PROFESSIONAL AND BUSINESS AFFILIATIONS AND ASSOCIATIONS: SPECIAL RECOGNITION, HONORS OR AWARDS: MISCELLANEOUS Page 3 HAVE YOU EVER SERVED ON ANY OTHER STATE BOARDS OR HELD ANY OTHER APPOINTIVE OR ELECTIVE POSITION IN STATE GOVERNMENT? IF YES, LIST POSITIONS AND DATES: DID YOU SEEK THIS APPOINTMENT? IF SO, WHY? WHAT EXPERIENCE OR EXPERTISE DO YOU FEEL YOU WOULD BRING TO THIS APPOINTMENT? DO YOU KNOW OF ANY REASON WHY ANY INDIVIDUAL OR GROUP WOULD BE OPPOSED TO YOUR NOMINATION? IF SO, WHY? PLEASE LIST ANY ORGANIZATIONS, BUSINESSES OR CORPORATIONS IN WHICH YOU OR YOUR SPOUSE OR CHILDREN HOLD ANY OFFICE, OWNERSHIP INTEREST, STOCKS OR BONDS, AND INDICATE THE NATURE OF YOUR RELATIONSHIP. Page 4 ARE YOU AWARE OF ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST ARISING OUT OF THIS APPOINTMENT PURSUANT TO TITLE 5, PARAGRAPH 18, 2. A-E, AS FOLLOWS: 2. EXECUTIVE EMPLOYEE. An executive employee commits a civil violation if he personally and substantially participates in his official capacity in any proceeding in which, to his knowledge, any of the following have a direct and substantial financial interest: A. Himself, his spouse or his dependent children B. His partners C. A person or organization with who he is negotiating or has agreed to an arrangement concerning prospective employment D. An organization in which he has a direct and substantial financial interest E. An organization with whom he has been associated as a partner or a fellow shareholder in a professional service corporation pursuant to Title 13, Chapter 22, during the preceding year. IF YOU HAVE A CONFLICT, WHAT STEPS HAVE YOU TAKEN OR DO YOU PLAN TO TAKE TO DISASSOCIATE YOURSELF FROM THIS CONFLICT SITUATION? ARE YOU OR HAVE YOU EVER BEEN A PARTY OF CIVIL OR CRIMINAL COURT LITIGATION EITHER PERSONALLY OR AS AN OFFICER OR A CORPORATION, ASSOCIATION, OR OTHER LEGAL ENTITY? DESCRIBE THE CIRCUMSTANCES OF ANY SUCH LITIGATION. Page 5 HAVE YOU EVER BEEN SANCTIONED OR REPRIMANDED BY A PROFESSIONAL OR OCCUPATIONAL BOARD? WHAT ACTION WAS TAKEN? WOULD YOU HAVE ANY OBJECTION TO HAVING A BACKGROUND CHECK RUN ON YOUR MOTOR VEHICLE AND CRIMINAL RECORD? 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