Application for Gubernatorial Appointment

Thank you for your interest in serving on Vermont’s Boards and Commissions. The Governor’s Office will process your application and contact you if necessary.

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Format: 000-000-0000
Format: 000-000-0000

Mailing Address

Format: 00000 or 00000-0000

Format: 000-000-0000

Select the name of the board or commission you are interested in being appointed to. Please select “Other” if you would like to offer your services in general, and indicate your areas of interest on the application.
Include name of board/commission and dates you served.
Max 3,000 characters.
** Immediate family includes: spouse, domestic partner, child, parents, siblings
** Immediate family includes: spouse, domestic partner, child, parents, siblings

Please provide a BRIEF biography about yourself. This information may be used on a public website so please do not include any personal information.
Formats allowed: .pdf, .doc, .docx, .zip
Please list three persons unrelated to you that we can contact as a reference for your appointment:
Please include name, occupation, address, email and phone number(s).
Please include name, occupation, address, email and phone number(s).
Please include name, occupation, address, email and phone number(s).

Some statutes creating a board may require this information to ensure balance.

Diversity

The following optional information is elicited in order to ensure that this administration considers the talent and creativity of a diverse pool of candidates. In addition, specific backgrounds for qualifications are legally required for appointment to some boards and commissions. You may, therefore, wish to provide this information in order to ensure that you are considered for relevant boards and commissions.


Authorization and Attestation

We may conduct a background investigation for certain board appointments as warranted. The Governor’s Office considers the information we obtain to be confidential. The Governor’s Office will not release this information for public inspection unless required to do so. Information submitted on this application will be confidential to the extent permitted by Vermont law.

I hereby authorize that my criminal record history and tax records be released to the Governor or the Governor’s representative and certify that the information provided in this application is true, correct and complete to the best of my knowledge. I further authorize the disclosure of my application to the Vermont Senate should I be appointed to a position that requires the advice and consent of the Senate.

Contact Information

Office of Governor Phil Scott
109 State Street, Pavilion
Montpelier, VT 05609
Phone: 802 828-3333 (TTY: 800 649-6825)
Fax: 802 828-3339

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