Mike DeWine Governor

Please complete this applicaton and return, along with resume or bio, to: boards.commission@governor.ohio.gov.

Date

Today's Date

The State of Ohio is an equal opportunity employer and will not use any of the information you provide to discriminate against you on the basis of race, color, religion, gender, gender identity or expression, national origin (ancestry), military status (past, present or future), disability, age (40 years or older), status as a parent during pregnancy and immediately after the birth of a child, status as a parent of a young child, status as a foster parent, genetic information, or sexual orientation. If you need more space to answer any question or explain any of your answers, please use additional sheets. This information MUST BE COMPLETED IN FULL.

Pursuant to Ohio law all appointees to a statutory board or commission are required to file an annual financial disclosure statement with the Ohio Ethics Commission. A financial disclosure statement requires a filer to disclose certain information regarding their personal financial interests and fiduciary relationships for the preceding calendar year. A sample financial disclosure statement is available here https://ethics.ohio.gov/forms/fds/index.html. A financial disclosure statement may be a “public statement” which is publicly available, or it may be a “confidential statement” which is not publicly available. The distinction between a “public statement” and a “confidential statement” is based in law and is a function of the particular body that an appointee is a member of. Most but not all uncompensated appointees are “confidential” filers. A listing of these distinctions by particular body is available here https://ethics.ohio.gov/fds/membersrequiredtofile.pdf.

Please note, if you currently receive benefits from a state retirement agency, you may wish to discuss with that agency any potential impacts on your benefits should you be appointed to a state board or commission.

Full Legal Name

Residence Address

City

State

Zip Code

County of Residence

Length of Residence in Ohio

Home Phone Number

Cell Phone Number

Business Phone Number

Email Address

Confirmation Email

Current Business / Employer

Title/Position

Business Address

City

State

Zip Code

NOTE: The Ohio Revised Code sets forth demographic qualifications for service upon many boards and commissions. You must provide the demographic information required for service upon the board or commission to which you seek appointment. If you are unsure of whether demographic qualifications exist for a specific board or commission, please contact a Governor’s Boards and Commission staff member at 614-466-3555.

MaleFemale

Date of Birth:

Date of Birth

Race:

White: All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.Black or African American: All persons having origins in any of the Black racial groups of Africa.Hispanic or Latino: All persons of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origin, regardless of race.Asian: All persons having origins in any of the original peoples of the Far East, Southeast Asia, and the Indian Subcontinent for example, China, India, Japan, and KoreanNative Hawaiian or Pacific Islander: All persons having origins in any of the original peoples of the Hawaiian Islands and Pacific Islands for example, Hawaii, Phillippine Islands, and SamoaAmerican Indian or Alaskan Native: All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.Other: Please self-define

Are you registered to vote in Ohio?

YesNo

County of Voter Registration

Party Affiliation:

RepublicanDemocratUnaffiliatedOther

Please specify the board or commission that interests you

Do you currently serve on a gubernatorial board or commission? If yes, please identify

Are you seeking reappointment?

YesNo

Have you ever previously served as a gubernatorial appointee on a board or commission? If yes, please identify the board or commission on which you served, and when you served:

Have you ever been a member of the armed forces of the United States, its reserve components or the National Guard? If yes, please state branch, service period, and last rank, and please indicate if you did not receive an honorable discharge, were ever court-martialed, were ever assessed non-judicial punishment, resigned in lieu of court-martial, or were administratively discharged:

Are you now under any indictment, bill information, criminal complaint or any other type of criminal complaint for charge or charges for any crime federally including any military court, in this state, any other state, any tribal reservation, any territory of the United States, or outside the United States? If yes, please identify. If the charges were filed inside the United States, please include the county or parish where those charges were filed.

Have you ever, as an adult, been charged with any crime or arrested for any crime excluding minor traffic offenses (regardless of whether you were convicted of acquitted) federally including any military court, in this state, any other state, any tribal reservation, any territory of the United States, or outside the United States? If the charges were filed inside the United states, please include the county or parish where those charges were filed. For this question, if the charge ended in a plea deal, please indicate the crime for which you were charged in addition to the crime to which you pleaded guilty. Further, minor traffic offenses are traffic offenses which could not be sentenced to a term in jail. For example, speeding or parking violations are not jailable, but OVI is a jailable offense. Failure to fully list committed offenses may be considered a lack of candor. If yes, please identify in full and completely:

To your knowledge, are you personally currently under investigation for any violation(s) of law? If yes, please identify:

Have you ever been named as a party (i.e. defendant) in a civil action in this state, any other state, in federal court or outside the United States? If yes, please identify:

Are you currently bringing, or have you ever brought, a civil action against the State of Ohio i.e. state agency, board or commission, etc, any other state, political subdivisions of any state i.e. cities, counties, townships, etc, or the United States any agency of the federal government? If yes, please identify

Has any civil protection order (CPO) or restraining order or emergency custody order relating to domestic violence or any other subject ever been entered against you? If yes, please identify

Have you ever had any civil, administrative, or arbitration judgment or garnishment entered against you or against any business in which you were owner or the majority shareholder? If yes, please identify:

Have you ever filed personal bankruptcy or been adjudicated bankrupt? If yes, please provide details

Are you currently in arrears on any court-ordered child support payments? If yes, please identify:

Has any business that you have owned, or of which you have been the majority shareholder, ever filed for bankruptcy or been adjudicated bankrupt? If yes, please identify:

Have you ever failed to pay any government-insured debt or any debt owed to a government entity? If yes, please identify:

Have you ever applied for, or held a license for a business, trade, or profession that required proof of good character or examination? If yes, please identify the license and issuing authority:

Have you ever been denied such a license, had that lic ense revoked or suspended, or been disciplined with respect to that license? If yes, please explain

Have you ever been disciplined for, or has any action ever been taken against you by any public or licensing authority or professional organization for any breach of ethics or unprofessional conduct or failure to make required disclosures? If yes, please identify

Are all your federal, state and local taxes current? If no, please explain:

Within the past three years, has any business venture for which you were an owner or person responsible for remitting withholding taxes of sales taxes, failed to pay such taxes in a timely manner? If yes, please explain:

Have you ever received, other than as an employee, or has any business that you owned or of which you were the majority shareholder, ever received any income from the Ohio state board or commission to which you seek appointment? If yes, please identify the income:

Have you ever received income as a lobbyist or “legislative agent“ as defined in the Ohio Revised Code section 101.70 or “executive agency lobbyist” as defined in Ohio Revised Code section 121.60 for work related to the Ohio General Assembly, any Ohio elected officer or any agency or entity of the executive branch of the Ohio state government? If yes, please identify the entity receiving the income:

Are you a United States citizen? If no, please state immigration status:

Do either you or your spouse own or are either you or your spouse the majority shareholder of any business that will derive income from the Ohio state board or commission to which you seek appointment? If yes, please identify the business and the amount of annual income anticipated:

Do you have, or have you had, any personal, financial or business interest or dealings that might present a conflict of interest with your proposed state appointment? If yes, please identify:

Identify and describe any other information or situation that others might perceive as a conflict of interest with your proposed state appointment, or which might cause embarrassment to the state should you be appointed to a state board or commission

Have you been publicly identified with a particularly controversial national, state, or local issue, or with an issue under the supervision of the board or commission to which you seek appointment? If yes, please explain

Have you ever (1) made statements, including written or on social media, concerning a controversial issue, or (2) associated with controversial group which would bring discredit to you or the office that you seek?

EDUCATION/TRAINING (if you need more space, please attach additional sheet). Did you graduate high school?

YesNo

Did you obtain a GED?

YesNo

High School Name

Location (City, State)

Check Year Completed:

9101112

School Name (College/University/Vocational or Technical)

Location (City, State)

Major/Degree:

Did you graduate?

YesNo

Check Year Completed:

School Name (College/University/Vocational or Technical)

Location (City, State)

Major/Degree

Did you graduate?

YesNo

Check Year Completed:

School Name (College/University/Vocational or Technical)

Location (City, State)

Major/Degree:

Did you graduate?

YesNo

Check Year Completed:

RELEVANT WORK EXPERIENCE (In additon to attaching your resume, please list your work experience that is relevant to the board to which you are applying. If more space is needed, attach an additional sheet:

1.

2.

3.

I, Full Name, acknowledge that I have reviewed this application in its entirety and certify that all of the answers and statements on this form are true, complete and correct to the best of my knowledge and recollection and are made in good faith.

Signature

I, Full Name, state that I understand that any information provided to the Governor's office may be a "public record" under Ohio law. I hereby waive any right to privacy of any information I have provided herein, and I authorize the Governor's office to investigate any of my responses.

Signature

Hitting submit will transmit this form to the Ohio Developmental Disabilities Council.

You can save a copy of this form by clicking the preview button and saving the file to your computer.

You are encouraged to e-mail along with resume to boards.commissions@governor.ohio.gov or mail to:

Boards and Commisions

Governor's Office

77 S. High St., 30th Floor

Columbus, OH 43215

Mike DeWine Governor

•• IN ADDITION TO THIS FORM, PLEASE SEND A RESUME OR BRIEF BIOGRAPHY BY E-MAIL TO BOARDS.COMMISSION@GOVERNOR.OHIO.GOV. ••

Ohio DD Council - New Member Application

Conflict of Interest

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