HomeMy WebLinkAbout2005-03 Board and Commission Application Forms .►<"Of NV Lincoln S.T.Ashida
Harry Kim
Corporation Counsel
Mayor •' "•
Gerald Takase
Assistant Corporation
Counsel
COUNTY OF HAWAII
OFFICE OF THE CORPORATION COUNSEL
101 Aupuni Street, Suite 325 • Hilo,Hawaii 96720-4262 • (808)961-8251 • Fax(808)961-8622
August 2, 2005
MEMORANDUM Memorandum 2005-03
TO: OFFICE OF THE MAYOR
HAWAII COUNTY COUNCIL
ALL COUNTY DEPARTMENTS
ALL COUNTY BOARDS AND COMMISSIONS
FROM: LINCOLN S. T. ASHIDA
Corporation Counsel
RE: Board and Commission Application Forms
In recent months, the County of Hawaii has worked towards encouraging
as many citizens as possible from our County to submit applications for
appointment to a Hawaii County board and/or commission.
Through the dedicated hard work of the staff at the Mayor's Office of
Information and Complaints, we have a sizeable pool of applicants. We wish to
encourage and increase the number of applicants, so our boards and
commissions are staffed with a variety of citizens from different backgrounds and
with different interests.
We need your help. We never want to turn an applicant away by saying,
"You need to go to another office to get an application."
Please make copies of the attached updated application form, and have
them available at your office for distribution to the public. If you would like this
form sent to you via e-mail, please contact Martha Rodillas at
Mrodilla(a)-co.hawaii.hi.us. For those departments with offices around the island,
we would appreciate you making copies of the application form and this memo
for them.
Thank you for your cooperation in this matter. If you have any questions
concerning board and commission vacancies, please direct them to our attention.
Encl.
S: Boards and Commissions/LSA Forms and Documents/Memo 2005-03 re application form 8-2-05/LSAmr
Hawaii County is an Equal Opportunity Employer and Provider
11/04
APPLICATION FOR HAWAII COUNTY BOARDS AND COMMISSIONS
Our goal, in addition to meeting State and County regulations regarding the composition of a particular board or
commission, is to select members who bring a variety of skills and life experiences to these agencies. The answers to the
following questions can assist us in these efforts.
NAME DATE
Last First Middle
RESIDENCE ADDRESS
City State Zip
MAILING ADDRESS
City State Zip
PHONE
Home Business Cell Fax
U.S. CITIZEN ❑Yes ❑ No HAWAII COUNTY VOTER ❑ Yes ❑ No COUNCIL DISTRICT
(Call 961-8277 if not sure)
DATE OF SOCIAL LENGTH OF RESIDENCE
BIRTH SECURITY NO. IN HAWAII
MARRIED ❑Yes ❑ No NAME OF SPOUSE
EDUCATION
EMPLOYMENT RECORD (Past ten 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.
Are you currently an official and/or card carrying member of any of the following political parties?
❑ Democrat ❑ Republican ❑ Green ❑ Libertarian ❑ None
COMMUNITY SERVICE (Organizations; offices held; indicate past or present):
1. 3.
2. 4.
MILITARY SERVICE RECORD
Applicable laws require the pre-disclosure of any existing or potential conflicts of interest. Should you have any such
conflicts of interests which may be questioned, 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 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.
1 hereby acknowledge and attest that the foregoing information provided by me is true and correct to the best of my
information and belief. I hereby waive any and all right to privacy and authorize the Office of the Mayor and its
employees, agents and assigns to investigate and obtain information concerning my fitness and/or ability to serve as an
appointee of the County of Hawaii. I herein waive any and all claims against the County of Hawaii, its officers,
employees, agents and assigns, and any person and/or entity furnishing information,for liability and/or damages as a
result of the dissemination and obtaining of this information.
SIGNED BY
THE INFORMATION CONTAINED IN THIS APPLICATION IS CONFIDENTIAL AND IS SOLELY INTENDED FOR USE
BY THE MAYOR'S OFFICE IN MATTERS PERTAINING TO BOARDS AND COMMISSIONS. IF YOU HAVE ANY
QUESTIONS, PLEASE CALL THE OFFICE OF INFORMATION AT 961-8223.
PLEASE RETURN COMPLETED FORM TO:
MAYOR'S OFFICE, COUNTY OF HAWAII
25 AUPUNI STREET,#217
HILO, HI 96720