State of Vermont

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.

First Name *

Middle Initial .

Last Name *

Suffix

Email *

Date of Birth *

Day

Month

Year

Phone *

Format: 000-000-0000

Mobile Phone

Format: 000-000-0000

Town of Residence *

Year Round Resident *

Yes

Mailing Address

Street Address *

Address Line 2

City/Town *

State *

Zip Code *

Format: 00000 or 00000-0000

Occupation *

Current Employer *

Business Phone

Format: 000-000-0000

Business Address

Board/Commission Name *

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.

Have you ever been elected or appointed to public office (including other boards or commissions)? *

Yes

If yes, please list:

Include name of board/commission and dates you served.

Please list association memberships:

Have you held or do you hold an occupational or professional license or certificate in the State of Vermont or any other state? *

Yes

Please note the type of license/certificate and the issuing authority:

Have you ever had disciplinary action of any nature taken against you with regard to such license?

Yes

If yes, please provide full details:

Max 3,000 characters.

Have you been, or are you now, a registered lobbyist? *

Yes

If yes, please list the principals you represent(ed) and dates:

Have you or members of your immediate family** or businesses in which you or they have been an owner, officer, or employee, had any contractual or other direct dealings during the last 4 years with any government agency? *

Yes

** Immediate family includes: spouse, domestic partner, child, parents, siblings

If yes, please explain:

If you are applying for a public member slot on a licensing board, have you or members of your immediate family** been a member of this profession or associated professions? *

Yes

** Immediate family includes: spouse, domestic partner, child, parents, siblings

If yes, please explain:

Brief Biography *

Please provide a BRIEF biography about yourself. This information may be used on a public website so please do not include any personal information.

Resume

Formats allowed: .pdf, .doc, .docx, .zip

Please list three persons unrelated to you that we can contact as a reference for your appointment:

1. Reference *

Please include name, occupation, address, email and phone number(s).

2. Reference *

Please include name, occupation, address, email and phone number(s).

3. Reference *

Please include name, occupation, address, email and phone number(s).

Are you able to attend daytime meetings? *

Yes

Are you able to spend time reading materials in preparation for meetings? *

Yes

Is there anything else you think we should know about you, your background, or experiences?

If you are appointed, is there anything about you not covered by the previous questions that might reflect poorly on the State of Vermont or on the Board or Commission to which you have applied, if known publicly? *

Yes

If yes, please explain:

Political Affiliation *

Democrat

Independent

Republican

Other

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

If "other" please provide:

How did you FIRST learn about the opportunity you are applying for?

Internet

News source

Word of mouth

Other

Name of publication, website, person, or other source:

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.

Race/Ethnicity

Gender

Age

Military Service

Person with Disability

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.

Your Full Name *

Today's Date *

Day

Month

Year

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

Public Records Database and Agency Records Officer or Liaison Contact Information

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Application for Gubernatorial Appointment

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