New Mexico Boards & Commissions Request for Appointment

Address

The Office of Governor Michelle Lujan Grisham is located on the 4th floor of the New Mexico State Capitol in Room 400.

Address:

490 Old Santa Fe Trail Room 400

Santa Fe, NM 87501

Phone: (505) 476-2200

New Mexico Boards & Commissions Request for Appointment

New Mexico Boards & Commissions Request for Appointment

Phone

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Your full name(Required)

First Last

Have you ever used a different name for school or employment? If so, please list the name(s) here.

Address(Required)

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Phone(Required)

Email(Required)

What racial or ethnic group(s) best describe you?

African American

Caucasian

Native American

Hispanic

Asian

Other

Date of Birth(Required)

MM slash DD slash YYYY

Marital status

Marital statusSingleMarriedDivorcedWidowed

Are you a New Mexico resident?(Required)

Are you a New Mexico resident?YesNo

If so, how long have you been a New Mexico resident?(Required)

Are you a registered voter?

Are you a registered voter?YesNo

Specific Board/Commission you are applying for

Other (Board/Commission you are applying for)

Explain why you are interested in serving on this board/commission\*

Are you related to an employee of the State Agency that oversees this board/commission(Required)

Are you related to an employee of the State Agency that oversees this board/commissionYesNo

What choice best fits your political affiliation?(Required)

What choice best fits your political affiliation?DemocratRepublicanIndependent/Decline to State

Have you changed your political party designation in the past 180 days?\*(Required)

Have you changed your political party designation in the past 180 days?\*YesNo

If yes, please provide the dates of the change(Required)

Have you ever been a candidate for any local, state, or federal political office?(Required)

Have you ever been a candidate for any local, state, or federal political office?YesNo

If yes, please list positions and, if elected, dates of service(Required)

Have you ever been appointed to any paid or unpaid local, state, or federal position?(Required)

Have you ever been appointed to any paid or unpaid local, state, or federal position?YesNo

If so, please identify the position, dates of service, and by whom you were appointed(Required)

Do you have any financial or other interests that might present a conflict of interest if you were to be appointed to the position for which you have applied? If yes, please explain in the space below(Required)

Do you have any financial or other interests that might present a conflict of interest if you were to be appointed to the position for which you have applied? If yes, please explain in the space belowYesNo

Have you ever received payment as a lobbyist or legislative agent?\*(Required)

Have you ever received payment as a lobbyist or legislative agent?\*YesNo

If so, please list the name(s) of the entity(ies) you represented(Required)

Have you ever been found guilty of any criminal law or a traffic violation for which you were fined more than $100?\*(Required)

Have you ever been found guilty of any criminal law or a traffic violation for which you were fined more than $100?\*YesNo

If yes, please explain in the space below(Required)

Are you currently involved, or have you been involved in the past five (5) years in a civil suit?(Required)

Are you currently involved, or have you been involved in the past five (5) years in a civil suit?YesNo

If you answered "yes," please provide an explanation(Required)

Have you ever been accused of sexual harassment?(Required)

Have you ever been accused of sexual harassment?YesNo

If you answered "yes," please provide an explanation(Required)

Please list all licensed professional or occupational membership affiliations(Required)

Are you currently an officer, director, partner, majority shareholder, managing member, or holder of a substantial interest in any corporation, partnership, or other business entity?(Required)

Are you currently an officer, director, partner, majority shareholder, managing member, or holder of a substantial interest in any corporation, partnership, or other business entity?YesNo

If yes, please list the name(s) and your relationship to the entity(ies)(Required)

Do you, your spouse, or any business in which you or your spouse hold 10% or more of the stock or membership interest, have any relationship with any federal, state, or local governments or Indian nation?(Required)

Do you, your spouse, or any business in which you or your spouse hold 10% or more of the stock or membership interest, have any relationship with any federal, state, or local governments or Indian nation?YesNo

If yes, please identify every instance(Required)

Have you filed all federal and state tax returns that are now due or overdue?(Required)

Have you filed all federal and state tax returns that are now due or overdue?YesNo

Have all tax payments, fines, penalties, and interest been paid in full and/or otherwise settled with the taxing authority?(Required)

Have all tax payments, fines, penalties, and interest been paid in full and/or otherwise settled with the taxing authority?YesNo

If no, please explain(Required)

Has a tax lien or other collection procedure every been initiated against you or your spouse by local, state, or federal authorities?(Required)

Has a tax lien or other collection procedure every been initiated against you or your spouse by local, state, or federal authorities?\*YesNo

If so, please describe the circumstances and the resolution of the matter(Required)

If there are specific designated requirements related to the desired appointment (e.g. age requiremnts, professional license, or any other statutory or constitutional specification), please state how you meet the requirements

I understand that the New Mexico Open Meetings Act may require that certain information contained in the application be available for inspection by the general public.(Required)

Yes, I understand

Education Level(Required)

Education LevelSome high schoolHigh school diplomaGED/CertificateSome college or technical schoolVocational tech certificateAssociate's degreeBachelor's degreeMaster's degreePost-graduate degreePh.D.

High school name(Required)

City and state of high school(Required)

Year graduated high school(Required)

References

Please provide at least 2 (up to 3) references with contact information.

Name of 1st reference:(Required)

First Last

Relationship of 1st reference(Required)

Phone of 1st reference(Required)

Email of 1st reference(Required)

Name of 2nd reference:(Required)

First Last

Relationship of 2nd reference:(Required)

Phone of of 2nd reference:(Required)

Email of of 2nd reference:(Required)

Name of 3rd reference:

First Last

Relationship of 3rd reference:

Phone of of 3rd reference:

Email of of 3rd reference:

Have you ever served on active duty in the United States Armed Forces, Military Reserves, or National Guard

Have you ever served on active duty in the United States Armed Forces, Military Reserves, or National GuardYesNo

Have you ever served on active duty in the United States Armed Forces, military Reserves, or National Guard

I agree to the following:(Required)

Email Governor.BCD@exec.nm.gov your most recent resume at your earliest convenience. By selecting this checkbox, I acknowledge that failure to do so may delay or disqualify my application.

Do you have a valid New Mexico driver's license?(Required)

Do you have a valid New Mexico driver's license?YesNo

If you do not have a driver's license please confirm below.(Required)

I do not have a driver's license

The Office of the Governor will conduct a criminal background check, including requesting a criminal history from the New Mexico Department of Public Safety. This information is kept strictly confidential and will not be released. Driver's license number:(Required)

Last four digits of your SSN(Required)

I hereby certify that:(Required)

This request contains no willful misrepresentation(s).

I understand that:(Required)

Should any investigation disclose such misrepresentation or falsification, my application will be rejected, my name removed from consideration for appointment, or I may be removed from appointment.

I understand that:(Required)

Submission of my request does not guarantee appointment. I understand that I may be required to submit to a background check as a condition of appointment.

I understand that:(Required)

Unsatisfactory results from, refusal to cooperate with, or any attempt to affect the result of these background checks will result in withdrawal of any offer or termination of appointment.

Signature

Clear Signature

Today's Date

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