Application for Mayoral Appointment to a Board or Commission

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The District of Columbia

Complete the form in full. Fields marked with * are required.
Allow for a three week processing time.
Provide draft language if applicable.

Requested By Outside U.S.

Prefix * First Name Initial * Last Name Suffix

* Address: WorkHomeOther

If work, enter company or organization:

* City:

* State: * Zip:

* Province:

* Postal Code:

* Country:

Add an Additional Address

* Address: WorkHomeOther

If work, enter company or organization:

* City:

* State: * Zip:

* Province:

* Postal Code:

* Country:

* Home Phone:

Work Phone: Cell:

Work phone format: xxx-xxx-xxxx ext12345

* Email:

Add an Additional Email

Email:

  Organization:

Secondary Address(optional)

Address:

Home Work

City:

State:

Zip:

Phone:

Home Work

Email:

Application for Appointment
* Board 1:
Board 2:
Board 3:
Other:

Personal Information

* Gender:

MaleFemale

* Date of Birth:

* Ethnicity:

Diversity:

Senior/Elder Citizen (60 years or older)

Young Adult(16 years to 24 years)

Person with Disabilities

Veteran of U.S Armed Forces

Gay, Lesbian, Bi-Sexual, Transgendered (GLBT)

Other

Education and general Qualification

* Did you Attend High Shool or receive a GED?			YesNo
Name of High School/GED:		School Location:
Did You Graduate?	YesNo	Last Year Attended:

* Did you Attend a College or post-secondary education?			YesNo
Name of College/University:		School Location:
Did You Graduate?	YesNo
Degree(s):		Major of Course:
Year:		Last Year Attended:

* Did you Attend a Graduate Postgraduate Program?			YesNo
Name of College/University:		School Location:
Did You Graduate?	YesNo
Degree(s):		Major of Course:
Year:		Last Year Attended:

Licenses Held (if applicable):

Special Skills and Qualifications:

Community Activities/Organizational Affiliations(current):

Declarations
* Are you a citizen of the United States?	YesNo
* Are you a Permanent Resident of the United States?	YesNo
* Are you registered to vote in the District of Columbia?	YesNo
* Are you a current employee of the U.S. government?	YesNo

* Are you a current employee of the District government?	YesNo
* Are you, or a family member, currently serving on board?	YesNo

* Have you ever had a professional/occupational license revoked, or suspended, as a result of desciplinary action?	YesNo
	If yes, please privde written details:
* Have you ever been convicted of, or pleaded guilty to, a crime?	YesNo
	If yes, provide written details:
* Is there anything in you background that might become an embarrassment to you if it were to become public?	YesNo
	If yes, provide written details:

Application Details
Comments:
Reference:
Resume: (Optional)

I certify that the facts and declarations contained in this application are true and correct to the best of my knowledge. I further authorize investigation of all statements contained herein and any personal references that I may include, or later provide, to obtain any and all pertinent information. I understand that providing false response may be cause to remove me from service on a board or comission, if appointed.

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