Oklahoma State Tax Commision

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Oklahoma State Tax Commision Powered By Docstoc
					                             STATE OF OKLA HOMA
                             OFFICE OF THE GOVERNOR

APPLICATION FOR GUBERNATORIAL APPOINTMENT TO A BOARD OR COMMISSION

Application Instructions:
        Co mplete the entire application form (copies of the form are acceptable).
        Applicants are strongly encouraged to attach a current resume or b iography.
        Specifically list the names of the boards or commissions to which you are applying (multip le selections are allowed).
         Paperwork cannot be appropriately processed unless specific boards or commissions are listed.
        Return applicat ion along with your resume to:
         Office of the Governor, 2300 N. Lincoln B oulevard, Suite 212, Oklahoma City, OK 73105 or by fax at (405) 521-3353.
        This form can be obtained electronically at http://www.gov.ok.gov, or by calling the Governor’s Office at: (405) 522-8804.

Board(s) or Co mmission(s) for which you would like to be considered:
         _____________________________________________________________________________________
         ______________________________________________________________________________________________

Your Fu ll                                                    Your
Legal Name: _________________________________________________ Preferred Name: ________________________________


 The following information is necessary to complete your OSBI background check:
 Previous Legal Names: _________________________________________________________________ Sex (M/F): __________
 Social Security #: ________________________Driver’s License #: ________________________ Date of Birth: _____________



Business Name: ____________________________________                      Ho me Address:_________________________________________

Job Title/ Employment Date: _________________________                    City, State Zip:_________________________________________

Business Address: __________________________________                     County: _______________________________________________

__________________________________________________                       Ho me Phone: __________________________________________

Business Phone: ____________________________________                     Cell Phone:____________________________________________

Fax: ______________________________________________                      Ho me Email:___________________________________________

Business Email: ____________________________________                     Spouse’s Full Name: ____________________________________


State Senator: _____________________________________                     State Representative: ____________________________________
                       (http://www.lsb.state.ok.us – Find Your Legislator – M UST BE FROM YOUR HOME ADDRESS)

Your Party Affiliation: ______________________________                   Your Congressional District: ______________________________
                         (for tracking purposes only)

Are you registered to vote in the State of Oklaho ma?  Yes          No      Are you a citizen of the United States?           Yes    No



   Personal Information:
   The Governor desires a broad representation of backgrounds on boards and commissions. The information below is voluntary.

   Of what race or ethnicity do you consider yourself to be?
    Black/African-A merican  White/Caucasian  Hispanic  Asian                         Native A merican         Other______________


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Education (high school, name and l ocation of college or uni versity, year graduated, and degree):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________________________________________________________________ ____________

Current empl oyment (job descri ption, employment date, supervisor):
____________________________________________________________________________________________________________
___________________________________________________________________ _________________________________________
____________________________________________________________________________________________________________

Previous empl oyment or experience:
______________________________________________________________________ ______________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Professional Licenses Hel d (if applicable):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Professional References (name, title, contact phone number):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________ ________
___________________________________________________________________________________________________________

Membershi ps in professional or ci vic organizati ons (please include offices hel d and dates of terms):
____________________________________________________________________________________________________ ________
____________________________________________________________________________________________________________
_____________________________________________________________________________________ _______________________

Military Service Record (includi ng awards, decorations, etc.):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Have you ever been elected or appoi nted to any public office, board or commission in the State of Oklahoma?  Yes  No
(If yes, please list with dates served)
_____________________________________________________________________________________________ _______________
________________________________________________________________________________________________ ____________

Do you have any financi al or other i nterests that might present a conflict of interest, or the appearance of such a conflict, if
you were to be appointed to the position for which you have applied?  Yes (please explain)  No
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
______________________________________________________ ______________________________________________________

Please list any s pecial interests or characteristics which might be i mportant to serve on a Board or Commission:
_______________________________________________________________________________________ _____________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Is there anything i n your background that might become an embarrass ment to you if it were to become public?  Yes (please
explain)  No
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________



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Have you ever been convicted of or found to have commi tted a cri me or offense? (Do not include traffic offenses for which the
fine was less than $200.)
          Yes  No. If yes, please provide details (including date, court, crime and sentence) of:
                                Each felony conviction;
                                Each traffic vio lation resulting in a jail sentence (actual or suspended) or fine in excess of $ 200;
                          and
                                Each misdemeanor resulting in a jail sentence (actual or suspended) or a fine in excess of $200.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

Citations: Have you ever been cited for a breach of ethics for unprofessional conduct by, or been named in, a complaint to any court,
administrative agency, professional association, disciplinary co mmittee, including the Oklaho ma Ethics Co mmission, or other
professional group?                Yes  No. If yes, please provide details. _______________________________________
__________________________________________________________________________________________________________

Tax Compliance: Are you currently in good standing with the Oklaho ma Tax Co mmission and the IRS?  Yes No (p lease exp lain)
___________________________________________________________________________________________________ _______
__________________________________________________________________________________________________________

Have you ever NOT been in compli ance or in good standi ng wi th the Oklahoma Tax Commission or the IRS?  Yes No
(please explain)______________________________________________________________________________________________
___________________________________________________________________________________________________________

Are you currently a registered lobbyist in Oklahoma?               Yes  No.
(Note: In most instances, registered lobbyists are not eligible for gubernatorial appointments .)


RELEAS E OF INFORMATION

I do hereby authorize representatives of Governor Brad Henry to have access to my emp loyment records with my current and former
emp loyers, educational records, financial records, records maintained by federal and state law enfo rcement agencies or tax agencies,
reports of credit agencies, and any other information they may request of my current and former employers or cred itors which is not in
conflict with state or federal law, regarding their background investigation of me to b e conducted for the purpose of appointment by
the Governor.

I authorize the use of any informat ion contained in the APPOINTMENTS APPLICATION to verify my statements made in the
Application. I authorize my past employers, all references, and any other persons to answer all questions asked concerning my ability,
character, reputation and previous education or employ ment record. I release all such persons from any liability or damages on
account of having furnished such information. I consent to such investigations as Governor Brad Henry or h is authorized
representatives may make regard ing driv ing records, law enforcement records, credit reports and my general backg round.

I certify under penalty of perjury under the laws of the State of Oklaho ma, that the above informat ion is true, complete and correct to
the best of my knowledge.



__________________________________________                       __________________________________________________
Signature                                                        Date




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