Nominate Yourself

OFFICE OF EXECUTIVE APPOINTMENTS
APPLICATION FOR GUBERNATORIAL APPOINTMENT

As a citizen of Illinois, you are invited to use the form below to nominate yourself for membership on up to four boards, commissions, councils, or task forces. The information we collect will be used by the Governor's office in considering your interest in an appointment. It will be kept confidential and protected from disclosure to the extent permitted by law. If you have problems completing the form, please email

gov.appointments @ illinois.gov

Required Fields. Please provide accurate information in ALL required fields.

PART A: Board or Commission Sought (Choose up to four in order of preference)

1^st Choice:
2^nd Choice:
3^rd Choice:
4^th Choice:

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PART B: Basic Information

First Name:
Middle Name:
Last Name:
Have you ever used or been known by any other legal name?: Yes No If yes, please give prior name:
Spouse / domestic partner's Name:
Home Address:
City:
State:
Zip Code:
Email Address:	Sign me up for a Governor's e-Newsletter Subscription
Home Phone:	Ext:
Work Phone:	Ext:
Cellular Phone:
Business Address:
City:
State:
Zip Code:

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PART C: Demographic Information

Gender: Male Female
Ethnicity: White not of Hispanic Origin. A person having origins in any of the original peoples of Europe, North Africa or the Middle East. African American not of Hispanic Origin. A person having origins in any of the black racial groups of Africa. Native American. A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa. Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish Culture or origin, regardless of race. Other No Response
Disability: Yes No If yes: Type of Disability:
Veteran: Yes No If yes: Dates of service: Branch or component: Date and type of discharge:
Under State law, certain boards and commissions are required to have diversity of membership based on political affiliation. If you are applying for a position on such a board or commission and would like to furnish your political affiliation (if any) to the Office of Executive Appointments for inclusion in your application, please do so here. Are you a registered voter? Yes No If yes: Identify the county in which you are registered to vote: Party: If other Please specify: Please Note: If you are unsure as to your party affiliation please visit Election Authorities page and find your County Clerk. They will be able to provide this information.
Date of Birth:	MM/DD/YYYY
Place of Birth:

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PART D: Education

High School Name:

High School Location:

List the last four post-secondary educational institutions attended. List the most recent school first:

Row Number	Institution	Location	Dates Attended	Certificates/Degrees Received
1
2
3
4

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PART E: Employment and Professional Qualifications

Please provide your employment history for the last five years. List your most recent employer first.

Work Experience

Row Number	Employer	Title or Type of Business	City and State	From	To
1
2
3
4

Professional licenses and certificates

Row Number	License or Certificate	Date Issued	Jurisdiction
1
2
3
4

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PART F: Government Affiliations and Experience

Are you a public official?: Yes No If yes, what office do you hold?: 3000 chars remaining (max. 3000 chars)
Is your spouse / domestic partner a public official?: Yes No N/A If yes, what office does your spouse / domestic partner hold?: 3000 chars remaining (max. 3000 chars)
Are you a lobbyist registered with the State of Illinois?: Yes No NOTE: The Illinois Ethics Act restricts registered lobbyists from serving on certain boards. Please review (25 ILCS 170/3.1) to determine your eligibility.
Is your spouse / domestic partner a lobbyist registered with the State of Illinois?: Yes No N/A
Are you a government employee?: Yes No If yes, which unit of government do you work for?: 3000 chars remaining (max. 3000 chars)
Is your spouse / domestic partner a government employee?: Yes No N/A If yes, which unit of government does your spouse / domestic partner work for?: 3000 chars remaining (max. 3000 chars)

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PART G: Interest and Qualifications

Why would you like to serve on the board(s) you have selected? If you are interested in reappointment, serving as Executive Director or any other specific position (e.g. "Chair" or "Treasurer"), please also indicate that here. Interest
3000 chars remaining (max. 3000 chars)

What unique characteristics, qualifications and experiences would you bring to a board or commission?: Unique Characteristics, Qualifications and Experiences
3000 chars remaining (max. 3000 chars)

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PART H: Certification

By clicking the "Submit" button below I hereby certify that the foregoing responses are true, accurate and complete. I agree that any misstatement, misrepresentation, or omission of fact may result in my immediate disqualification for appointment. I authorize the State of Illinois to review my credit and criminal history, and/or to request more information about my background.

I further certify that I have read the Revolving Door provisions of the Illinois Ethics Act and if appointed, I agree to abide by them. required

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Main Navigation

Nominate Yourself

OFFICE OF EXECUTIVE APPOINTMENTS
APPLICATION FOR GUBERNATORIAL APPOINTMENT

PART A: Board or Commission Sought (Choose up to four in order of preference)

PART B: Basic Information

PART C: Demographic Information

PART D: Education

PART E: Employment and Professional Qualifications

PART F: Government Affiliations and Experience

PART G: Interest and Qualifications

PART H: Certification

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Main Navigation

Nominate Yourself

OFFICE OF EXECUTIVE APPOINTMENTSAPPLICATION FOR GUBERNATORIAL APPOINTMENT

PART A: Board or Commission Sought (Choose up to four in order of preference)

PART B: Basic Information

PART C: Demographic Information

PART D: Education

PART E: Employment and Professional Qualifications

PART F: Government Affiliations and Experience

PART G: Interest and Qualifications

PART H: Certification

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OFFICE OF EXECUTIVE APPOINTMENTS
APPLICATION FOR GUBERNATORIAL APPOINTMENT