HomeMy WebLinkAboutmalameda@hawaiicounty.gov 8
APPLICATION FOR HAWAII COUNTY BOARDS AND COMMISSIONS
Our goal is not only to comply with State and County regulations concerning board and commission composition but also
to select members who contribute a diverse range of skills and life experiences. The answers to the following questions
will help us achieve this objective.
NAME DATE
Last First Middle
RESIDENCE ADDRESS
City State Zip
MAILING ADDRESS
City State Zip
PHONE
Home Business Cell Fax
E-MAIL
U.S. CITIZEN ❑ Yes ❑ No HAWAII COUNTY VOTER ❑ Yes ❑ No COUNCIL DISTRICT
(Call 961-8277 if not sure)
DATE OF *Last 4 SOCIAL LENGTH OF RESIDENCE
BIRTH SECURITY NO. IN HAWAII
MARRIED ❑Yes ❑ No NAME OF SPOUSE
EDUCATION
EMPLOYMENT RECORD (Past 10 years)
From (Year) TO (Year) EMPLOYER OCCUPATION
Are you currently serving on any federal, state, or county board or commission? ❑ Yes ❑ No
If yes, name the entity and date your term ends:
List by preference the board or commission you wish to serve on:
1. 3.
2. 4.
Briefly explain your interest in being a member of a particular board or commission.
COMMUNITY SERVICE (Organizations; offices held; indicate past or present):
1. 3.
2. 4.
MILITARY SERVICE RECORD
Applicable laws require the disclosure of any existing or potential conflicts of interest. If you have any conflicts of
interest that may raise concerns, please describe them below:
Some of the boards and commissions require the filing of a Financial Disclosure Statement. If required, would you
comply? ❑ Yes ❑ No
Have you ever been convicted of a violation of the law? ❑ Yes ❑ No
If yes, explain. NOTE: A conviction record will not be deemed a basis of denial for consideration unless the offense is
related to the board or commission for which you have applied.
PERSONAL REFERENCES
1.
2.
I hereby acknowledge and attest that the information I have provided is true and accurate to the best of my knowledge
and belief. I waive any right to privacy and authorize the Office of the Mayor, along with its employees, agents, and
assigns, to investigate and obtain information regarding my suitability to serve as an appointee of the County of Hawai'i.
I also waive any claims against the County of Hawai'i, its officers, employees, agents, assigns, and any person or entity
providing information, for any liability or damages arising from the dissemination or acquisition of this information.
SIGNED BY
The information provided in this application is confidential and intended exclusively for use by the Mayor's Office in
matters related to boards and commissions. For any questions, please contact malairmneda. hawahcount I y or call
808 961-8211.
PLEASE RETURN THE COMPLETED FORM TO:
ATTN: BOARDSAND COMMISSIONS
OFFICE OF THE MAYOR,COUNTY OF HAWAI'I
25 AUPUNI STREET,Suite 2603
HILO, HI 96720
Or Fax the Form to:
808-961-6553
*This information is requested for the purpose of conducting a criminal history check only.