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Nominate Yourself

OFFICE OF EXECUTIVE APPOINTMENTS
APPLICATION FOR GUBERNATORIAL APPOINTMENT

As a citizen of Illinois, you are invited to use the form below to nominate yourself for membership on up to four boards, commissions, councils, or task forces. The information we collect will be used by the Governor's office in considering your interest in an appointment. It will be kept confidential and protected from disclosure to the extent permitted by law. If you have problems completing the form, please email

requiredRequired Fields. Please provide accurate information in ALL required fields.

PART A: Board or Commission Sought (Choose up to four in order of preference)


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PART B: Basic Information

Have you ever used or been known by any other legal name?:required

      Ext:
      Ext:
     

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PART C: Demographic Information

Gender:
Ethnicity:





Disability:
If yes:
Veteran:
If yes:


Under State law, certain boards and commissions are required to have diversity of membership based on political affiliation. If you are applying for a position on such a board or commission and would like to furnish your political affiliation (if any) to the Office of Executive Appointments for inclusion in your application, please do so here.

Are you a registered voter?
If yes:

Please Note:
If you are unsure as to your party affiliation please visit Election Authorities page and find your County Clerk. They will be able to provide this information.

MM/DD/YYYY

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PART D: Education

List the last four post-secondary educational institutions attended. List the most recent school first:

Institution Location Dates Attended Certificates/Degrees Received
1
2
3
4

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PART E: Employment and Professional Qualifications

Please provide your employment history for the last five years. List your most recent employer first.
Work Experience
Employer Title or Type of Business City and State From To
1
2
3
4
 
Professional licenses and certificates
License or Certificate Date Issued Jurisdiction
1
2
3
4

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PART F: Government Affiliations and Experience

Are you a public official?:


3000 chars remaining (max. 3000 chars)
Is your spouse / domestic partner a public official?:


3000 chars remaining (max. 3000 chars)
Are you a lobbyist registered with the State of Illinois?:

NOTE: The Illinois Ethics Act restricts registered lobbyists from serving on certain boards. Please review (25 ILCS 170/3.1) to determine your eligibility.

Is your spouse / domestic partner a lobbyist registered with the State of Illinois?:
Are you a government employee?:


3000 chars remaining (max. 3000 chars)
Is your spouse / domestic partner a government employee?:


3000 chars remaining (max. 3000 chars)

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PART G: Interest and Qualifications

Why would you like to serve on the board(s) you have selected? If you are interested in reappointment, serving as Executive Director or any other specific position (e.g. "Chair" or "Treasurer"), please also indicate that here.


3000 chars remaining (max. 3000 chars)
 

What unique characteristics, qualifications and experiences would you bring to a board or commission?:


3000 chars remaining (max. 3000 chars)

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PART H: Certification

 

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