Application Form

Please fill out the following form to apply for a board.

Select a Board/Commission

Please select the board your would like to apply for:*

If interested in a specific position, please select one:

Basic Information

Prefix:*

First Name:*

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Middle Name:

Last Name:*

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Suffix:

Preferred Name:*

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Are you already a member of this board?:

Check if Yes

Home Address

Address Line 1:*

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Address Line 2:

City:*

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State:*

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Zip Code:*

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County:*

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This is my mailing address:

Check if Yes

Mailing Address

Address Line 1:*

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Address Line 2:

City:*

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State:*

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Zip Code:*

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County:*

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Contact Information

Email Address:*

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Work Phone Number:

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Mobile Phone Number:

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Home Phone Number:

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Preferred Number:*

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Education

High School:*

School Name

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Graduated

Yes

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Year Graduated

College:

College Name

Graduated

Yes

Year Graduated

Degree

Post Graduate:

College Name

Graduated

Yes

Year Graduated

Degree

Employment Status

Employer:*

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Job Title:*

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Please provide your current employment status:*

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Address Line 1:

Address Line 2:

City:

State:

Zip Code:

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County:

Phone Number:

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Fax Number:

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Email Address:

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Employment Date:

Contact Person:

Contact Phone:

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Professional Licenses held (if applicable):

References

Reference 1:

Name

Title

Organization

Relationship

Phone Number

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Reference 2:

Name

Title

Organization

Relationship

Phone Number

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Reference 3:

Name

Title

Organization

Relationship

Phone Number

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Previous employment or experience:

Memberships in professional, civic organiztions or government boards or commissions:

Community Service / Volunteer Activities:

Could you or your family be affected financially by decisions made by the board or commission for which you are applying?:

Yes

If yes please explain:

Have you been a registered lobbyist or have you employed a lobbyist at any time during the past five years?:

Yes

Board or commission meetings are held during the day. Are you able to come prepared and actively participate in day meetings?:

Yes

Why do you want to serve on this board or commission?:

Personal Information

Gender:*

Male

Female

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Race/Ethnicity:*

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Are you a citizen of the United States?:*

Yes

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Birth Date:*

Are you registered to vote in the state of North Carolina?:*

Yes

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Have you ever been convicted of or found to have committed a crime or offense? (Do not include traffic offenses for which the fine was less than $200.00):*

Yes

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If Yes, please explain:

Attachments

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I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorize the Governor’s Office to investigate any and all statements made in this application and understand that false information or documentation, or a failure to disclose relevant information may be grounds for rejection of my application. I further understand that dismissal upon appointment shall be mandatory if fraudulent disclosures are given to meet position qualifications (Authority: G.S. 14-122.1.)

Please check if you agree with the above statement:*

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