Application for Appointment

Personal Information:

First Name

Last Name

Age

Address

City

Zip

Township/Municipality

Resident of Dauphin Co. since

Phone Number

Email Address

JaneDoe@example.com

I request appointment to the following Board/Authority/Commission (Please list requests according to preference, with 1 being highest and 5 being lowest and note if you are asking for reappointment to a board you are currently serving on):

Please note that you do not need to list 5 Board/Authority/Commission requests.

1) Board/Authority/Commission

2) Board/Authority/Commission

3) Board/Authority/Commission

4) Board/Authority/Commission

5) Board/Authority/Commission

If applying for reappointment to your current Board/Authority/Commission, please check this box.

Applying for Reappointment

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Employment Information:

Current Employer

Job Title

Employer Address

Employer Telephone Number

Educational Background:

High School

Graduate?

College

Graduate?

Other Degrees/Certifications:

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Please answer all of the following questions:

If appointed, how much time can you devote to the municipal body?

On what date would you first be available for service? Are you able to attend all Board/Authority/Commission meetings? Please visit the list of Board/Authority/Commission websites.

Are you delinquent in the payment of Dauphin County, Municipality, or School District Real Estate Taxes? If NO, type "No" | If YES, please state particulars

Is any property in Dauphin County that you own presently subject to a tax lien for unpaid taxes OR do you have any controlling interest in a partnership, corporation or other entity which owns a property that is presently subject to a tax lien for unpaid taxes? If NO, type "No" | If YES, please state particulars

Are you a member of any organization where your membership may constitute an actual conflict of interest with Dauphin County or may give the appearance of a conflict of interest? Please note that this will not necessarily disqualify you from appointment. If NO, type "No" | If YES, please state particulars

Have you ever been convicted of a felony? If NO, type "No" | If YES, please state particulars

Have you ever been subject to a finding of sexual harassment?

Dauphin County adheres to the tenets of the Drug Free Workplace Act and has zero tolerance for the use of unlawful drugs in the workplace. Are you willing to support the provisions of this Act?

Have you ever been subject to a finding of child abuse?

Have you ever filed a petition in bankruptcy?

Are you an active member of any nonprofit, civic, charitable or community-based organizations? If NO, type "No" | If YES, please list organizations

Are you a registered voter?

What special skills do you possess (including hobbies and leisure activities) that may enhance your service?

Are you or have you ever been an employee of Dauphin County?

Are you currently serving on another Dauphin County Board/Authority/Commission? If so, are you willing to leave your current appointment if approved for another?

a) Yes, and I am willing to leave my current appointment if approved for another
b) Yes, but I am unwilling to leave my current appointment if approved for another
c) No, I am not currently serving on another Dauphin County Board/Authority/Commission

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Information required for background check

The information below is used solely for the purpose of the background check.

Full Name

Former Name(s); if any?

Social Security Number:

Date of Birth

Please briefly share what you feel you can bring in service to the Dauphin County Boards/Authorities/Commissions to which you are applying.

Please submit a professional resume with this application.

Signature & Date

I do solemnly swear (or affirm) that this application contains no misrepresentation, falsification or omission and that the information given by me is complete to the best of my knowledge and belief. Furthermore, I do solemnly swear (or affirm) that I will support, obey and defend the Constitution of the United States and the Constitution of the Commonwealth of Pennsylvania, and that I will discharge the duties of my office with fidelity. I consent to an investigation of my background and any information provided herein, including a criminal history check.

Signature

Date

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Application for Appointment

Board Application

Personal Information:

Employment Information:

Educational Background: