FALLON TRIIBAL DEVELOPMENT CORPORATIION
ALLON R BAL EVELOPMENT ORPORAT ON
565 Rio Vista Drive
Fallon, Nevada 89406
Tel 775.423.6075 / Fax 775.423.5202
FTDC Board of Director Application
Date of Birth: Social Security Number:
Tribal Affiliation: Enrollment Number:
Daytime Phone: Evening Phone:
Mobile Phone: Fax Number:
Email: Are you a Nevada Resident?
Employer: Supervisor Name:
Position: # of Years with Employer:
Have You Ever Been Bonded? YES NO
If selected, do you authorize the Fallon Tribal Development Corporation and/or the Fallon
Paiute-Shoshone Tribe to conduct a full fingerprint background check on you? YES NO
If selected, will you submit to pre-appointment and random drug testing in accordance with
the drug policy of the FTDC and/or FPST? YES NO
T R A IIN IIN G & E X P E R IIE N C E
TRA N NG & EXPER ENCE (submit resume and/or attach additional paper if necessary)
1) Educational Background. List both formal and informal education and training experiences.
Mark Last Did You Subjects Studied and
Name and Address of School and/or Source Year Completed Graduate? Degrees Received
High School or 1 2 Y
Equivalent Program 3 4 N
1 2 Y
3 4 N
1 2 Y
3 4 N
1 2 Y
3 4 N
(formal / informal)
2) Professional Qualifications, Work and Business Experience.
3) Community Activities and/or Other Experience. Tribal, Professional, Civic and Community, religious institutions,
neighborhood associations and any other groups. Please note if you hold an executive position, including Board of Directors.
4) Governmental Experience. Describe your experience with working with Tribal, Federal, and Local Governments.
5) Tribal Experience. Describe your experience with working with Tribal Communities.
6) Reasons for Appointment. Explain why you would like to be considered for appointment to the Fallon Tribal Development
Corporation’s Board of Directors.
REFERENCES (please provide three (3) references not related to you)
Name Address & Phone Number Organization Acquainted?
C R IIM IIN A L O F F E N S E S
CR M NAL OFFENSES
Have you ever been convicted of any criminal offense or is there any criminal charge now YES NO
pending against you? (“Criminal offense/charge” means any felony or misdemeanor,
including driving while impaired, or any offense classified as “criminal traffic” – only traffic
offenses classified as and “infraction” is excluded.)
If “Yes,” submit a detailed written explanation in your own words describing the circumstances for
each offense/pending charge. Also submit a copy of the court judgment for any conviction not shown
on your criminal record report (or arrest warrant or bill of indictment from any pending charge).
L IIE N S O R J U D G M E N T S // B A N K R U P T C Y
L ENS O R JUDG MENT S BANKRUPTCY
Are there any liens or unpaid judgments now outstanding against you due to your failure to YES NO
pay a debt?
If “Yes,” submit a detailed written explanation in your own words of the circumstances and your efforts
to pay, as well as the name of the judgment creditor or lien holder (i.e., the party you owe), the
amount and date of the judgment or lien and the current balance.).
Have you ever filed for bankruptcy? YES NO
If “Yes,” submit a detailed written explanation in your own words of the circumstances, the date when
this action took place, as well as any other pertinent information regarding your bankruptcy
C E R T IIF IIC A T IIO N
CERT F CAT ON
I swear the information I have entered on this form is true to the best of my knowledge. I understand that if I deliberately
conceal or enter false information on this form my application may be rejected, I may be removed from the list of eligible
candidates, or I may be removed from the position. I authorize the Fallon Tribal Development Corporation and/or Fallon Paiute
Shoshone Tribe or their designee to contact present or former employers, employees, or other persons who know me to obtain
additional information about my skills and abilities. I understand that if selected, I will be required to provide the Corporation
and/or Tribe with additional information and documentation necessary to conduct my full background check as well as provide
documentation necessary for the operations of the Fallon Tribal Development Corporation.