HomeMy WebLinkAboutApplication for Hawaii County Boards and Commissions 08/10
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
E-MAIL
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 political party? ❑Yes ❑ No
If'yes,"what political party?
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.
I 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:
OFFICE OF THE MAYOR, COUNTY OF HAWAII
25 AUPUNI STREET,#2602
HILO, HI 96720
'This information is requested for the purpose of conducting a criminal history check only.