MICHAEL L PARSON boards mo gov

Michael L Parson Boards Mo Gov-Free PDF

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GUBERNATORIAL APPOINTMENT APPLICATION,Application Instructions. Complete the entire application form and include current photo and resume Please no biographies Failure to respond to. any question will make your application incomplete Please answer none or not applicable where appropriate. You and your spouse if applicable must sign this Application and both the Gubernatorial and Senate Authorization forms. Specifically list the names of the boards and commissions to which you are applying multiple selections not to exceed. three 3 boards or commissions are allowed, Forward the completed application along with a current resume and photograph to our office by mail fax or e mail to. Governor Michael L Parson,P O Box 720,Jefferson City MO 65102. Telephone 573 751 3222,E mail boards governor mo gov. Board Commission Applying for,Are you seeking reappointment Yes No.
Last First Middle Initial, What other names have you used Include name changes nicknames maiden names and. former married names,Social Security No Driver s License No. Home Phone Work Phone,Cell Phone Fax,Email Address. Gender Male Female Date of Birth mo day year, Marital Status Single Married Divorced Separated Widow. Spouse s Full Name,Your ethnicity check one, White All persons having origins in any of the original peoples of Europe North Africa or the Middle East.
Black African American All persons having origins in any of the Black original peoples of Africa. Hispanic Latino a All persons of Mexican Puerto Rican Cuban Central or South America or other. Spanish culture or origin regardless of race, Asian All persons having origins in any of the original peoples of the Far East Southeast Asia or the. Indian Subcontinent, Native Hawaiian or Pacific Islander All persons having origins in any of the original peoples of the. Hawaiian Islands and Pacific Islands, American Indian or Alaskan Native All persons having origins in any of the original peoples of North. America and who maintain cultural identification through tribal affiliation or community recognition. Other Please self define,Are you a United States Citizen. Are you a Missouri resident How long,Current Residential Address.
Street Address,City County State Zip,Are you registered to vote at the above address. Your Congressional District State Senator,Your State Representative. Political Affiliation Democrat Republican Unaffiliated Other. Current Business Address,Street Address,City County State Zip. Specify your preferred mailing address Residential Business. List all your permanent and temporary places of residence for the last ten 10 years. Address City State From To,Address City State From To. Address City State From To, List all your current and former residences outside of Missouri that you have maintained at any.
time during adulthood including college addresses,Address City State From To. Address City State From To,Address City State From To. High School Dates Attended Year Graduated,High School Dates Attended Year Graduated. Postsecondary Education Dates Attended Certificate Degree Received. Postsecondary Education Dates Attended Certificate Degree Received. Postsecondary Education Dates Attended Certificate Degree Received. Please list all employment you have had for the last fifteen 15 years including your employer s. name business address type of business occupation or job title period s of employment and. reasons for leaving please attach extra sheets as necessary. Employer s Name Address Type of Business Occupation Job Title Date. Employer s Name Address Type of Business Occupation Job Title Date. Employer s Name Address Type of Business Occupation Job Title Date. Employer s Name Address Type of Business Occupation Job Title Date. Employer s Name Address Type of Business Occupation Job Title Date. Membership s in professional or civic organizations please note offices held and dates. Certificates or licenses please note dates acquired. Do you hold or have you previously held any local state or federal government positions. appointments or elected office s If so please list dates and positions held. Have you ever been a member of the Armed Forces of the United States its reserve components. or the National Guard If yes please state the branch service period and last rank and please. indicate if you did not receive an honorable discharge were ever court martialed were ever. assessed non judicial punishment resigned in lieu of court martial or were administratively. discharged, Has any civil litigation or garnishment action ever been filed against you If yes please identify. Has any civil order of protection or restraining order relating to domestic violence or any other. subject ever been entered against you If yes please identify. Have you ever had any civil administrative or arbitration judgment or garnishment entered against. you or against any business in which you were owner or the majority shareholder If yes please. Have you ever filed personal bankruptcy or been adjudicated bankrupt If yes please provide. Are you currently in arrears on any court ordered child support payments If yes please identify. Has any business you have owned or of which you have been the majority shareholder ever filed. for bankruptcy or been adjudicated bankrupt If yes please identify. Have you ever failed to pay any government insured debt or any debt owed to a governmental. entity If yes please identify, Have you ever applied for or held a license for a business trade or profession that required proof.
of good character or an examination If yes please identify the license the issuing authority and. the initial date of licensing, Have you ever been denied such a license had that license revoked or suspended or been. disciplined with respect to that license If yes please identify. Have you or your spouse ever been disciplined cited or sanctioned for a breach of ethics or. unprofessional conduct by or been the subject of a complaint to any court administrative agency. professional association disciplinary committee or other professional group If yes please. Are all of your federal state and local taxes current If no please explain. Within the past three years has any business venture for which you were an owner or person. responsible for remitting withholding taxes or sales taxes failed to pay such taxes in a timely. manner If yes please explain, Have you or your spouse ever received other than as an employee or has any business that you or. your spouse owned or of which you or your spouse were the majority shareholder ever received. any income from the Missouri state board or commission to which you seek appointment If yes. please identify the income, Have you ever been a registered lobbyist in Missouri If yes please identify. Do you have or have you had any personal financial or business interest or dealings that might. present a conflict of interest with your proposed appointment If yes please identify. Have you ever served as an appointed or elected official or a volunteer for a political party in. Missouri If yes please identify, Is there anything in your or your spouse s background that might become an embarrassment to you. if it were to become public Please consider carefully any letters to the editor blog posts etc you. or your spouse may have authored even anonymously If yes please explain. Have you or your spouse ever had any association with any person group or business venture that. could be used even unfairly to discredit or attack your character and qualifications for the position. to which you seek to be appointed If yes please describe. Have you or your spouse ever been publicly identified in person or by organizational membership. with a particularly controversial national or local issue or with an issue under the supervision of. the board or commission to which you seek appointment If yes please explain. Do you know of any person or group who might take overt or covert steps to attack even unfairly. your potential appointment If yes please explain, Have members of your immediate family spouse child parent s sibling s held any contractual.
or other direct dealings during the last four 4 years with any state or local government agency in. Missouri including the office or agency to which you are seeking If yes please explain. Have you or your spouse at any time belonged to any membership organization that as a matter of. policy or practice denied or restricted membership or affiliation based on race sex disability. ethnic background religion or sexual orientation or has been subject to a claim that it has done. so If yes please provide details, Please provide any other information including information about other members of your family. which could suggest a conflict of interest or be a possible source of embarrassment to you to your. family the Board Commission for which you are applying or to the Governor. References, Name Nature of Relationship Contact Information Years Known. Name Nature of Relationship Contact Information Years Known. Name Nature of Relationship Contact Information Years Known. CERTIFICATION,I print name certify that the information and. statements provided by me on this Application and on the attached materials are to the best of. my knowledge true and accurate,Applicant s Signature Date. Spouse s Signature Date,Press release, If you are appointed the Governor s office will issue a press release announcing your appointment.
pending completion of the process Please supply our office with the following information to be. used in such a press release and remember to include a recent photo along with your completed. Application and resume,Name of hometown,is job title and current place of employment. Name holds list earned degrees e g bachelor s master s etc. If you hold no degrees please list relevant job or community service experience. John A Doe 38 of Jefferson City is president of ABC Inc Doe holds a bachelor s degree in business. administration from XYZ University and a master s of business administration degree from ABC University. School of Business, John A Doe 38 of Jefferson City is the owner and operator of Doe and Associates Doe previously served. as division manager at ABC Company Doe is a certified personnel consultant. EXECUTIVE OFFICE STATE OF MISSOURI,AUTHORIZATION RELEASE. I name born at city,state on date and currently residing at address. county having, applied for a governmental appointment hereby consent to the release of information to the Office of the Governor I.
authorize and request every person firm company corporation government agency law enforcement agency court. associate or institution having control of any documents records or other information pertaining to me personally and. to any corporations partnerships or companies of which I am an owner or may be a responsible person for collection. of taxes under the tax laws of the state of Missouri to furnish to the Office of the Governor through the Missouri State. Highway Patrol any such information including all credit reports or documents records and files regarding charges or. complaints filed against me including any complaints erased by law whether formal or informal pending or closed or. any other pertinent data and to permit the Office of the Governor the Missouri State Highway Patrol or any of their. agents or representatives to inspect and make copies of such documents records or other information. I authorize and request the Missouri Department of Revenue to release confidential tax records for all tax period s to. the Office of the Governor through the Missouri State Highway Patrol This tax information may include but is not. limited to individual income tax sales tax use tax withholding tax or any other tax that is administered or collected by. the Department of Revenue pertaining to me personally and to any corporations partnerships or companies of which. I am an owner or may be a responsible person for collection of taxes under the tax laws of the state of Missouri The. Director of Revenue and Department personnel are hereby released from any and all liability pursuant to unauthorized. disclosures of confidential tax information resulting from release of information covered by section 32 057 RSMo. under this document, I authorize the custodian of my military records to release to the Office of the Governor through the Missouri State. Highway Patrol information for personal review or photocopies from my military personnel file and related medical. records or only the following information records This could include a photocopy of my DD. Form 214 Report of Separation, I along with my spouse name hereby release discharge and exonerate. the Office of the Governor the Missouri State Highway Patrol the Missouri Department of Revenue the State of. Missouri their agents and representatives and any person so furnishing information hereunder from any and all. liability of every nature and kind arising out of the furnishing or inspection of such documents records and other. information or any investigation or report made by the above persons or entities A copy of this release shall have the. same effect as the original, This authorization shall remain in full force and effect until the Office of the Governor is notified in writing that this. release has been revoked by the undersigned individual. Jefferson City MO 65102 Telephone 573 751 3222 E mail boards governor mo gov GUBERNATORIAL APPOINTMENT APPLICATION Application Instructions Complete the entire application form and include current photo and resume Please no biographies Failure to respond to any question will make your application incomplete Please answer none or not applicable where appropriate

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