COMMONWEALTH OF KENTUCKY INFORMATION FOR BOARDS AND COMMISSIONS

Return Completed Form To:
Brett Gaspard, Executive Director
Governor’s Office of Boards and Commissions Suite 132, State Capitol Frankfort, KY 40601 (FAX 502/564-2647)

Please indicate Boards/Commissions you wish to consider

Please submit a current resume with the application

Your Name (Last, First, Middle) Mr.
Ms. Mrs.	*County	*Congressional District	* Supreme Court District	
Home Address	City	State	Zip	
Date of Birth and Social Security Number	*Party Affiliation: Dem. Rep. Ind. (Underline one)	Race & Gender	
Your Occupation	Business Phone Number & Fax Number	Residence Phone Number	
Email Address	Mobile Number	
Current Employer	Business Address	
Spouse’s Name	Spouse’s Employer	

EDUCATION AND GENERAL QUALIFICATIONS:

Level	Name of School	No. Years Attended	Did you Graduate	Major Course(s) of Study	
High School					
College/Other					

Memberships in Organizations. Also Indicate Current Positions With Political Party or Organization.
Indicate Any Public Office
Currently Held.		

HAVE YOU EVER BEEN CONVICTED OF A FELONY?	IF YES, PLEASE INDICATE CHARGE, DATE AND PLACE.

By signing below, I understand the Governor’s Office may conduct a complete check on my background and do hereby authorize such an investigation.

REFERENCES (List two persons not related to you, whom you have known for at least one year)

Name	Address	Phone Number	Years Acquainted	

*Necessary for certain boards to comply with state law in regard to balance

DATE:		SIGNATURE: