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This Questionnaire is to be fully completed by each appointee. If required, a senate confirmation hearing to consider an appointee will not be scheduled until a completed questionnaire and all other related documents are received. Please answer each question completely to the best of your knowledge. If a question is not applicable, please so state. Please contact the governor's appointments office if you have questions when completing the form.

Before you begin the application process, please:
1. Have a copy of your resume ready in Word or PDF Format – you will be asked to attach before you submit your application.
2. Read through the questions to make sure you have the information needed to complete each question.
3. Have the contact information for your four (4) references available to complete the application.

General Information - All fields in this section in bold are required. Links on this form open in a new browser tab or window.

FULL NAME


     

     

   
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Appointing Authority:   Governor

HOME ADDRESS
   

                             

EMPLOYER BUSINESS INFORMATION
NOTE: If you are retired, please enter 'retired' in the Employer Business Name field and list your home address and the last position title held when you were employed.



Employer Business Address


        

CONTACT NUMBERS & EMAIL
         

      

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  (* This information will not be made public but is used by the KBI and Department of Revenue)

(mm/dd/yyyy)            

    

           
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In order to ensure that we are in compliance with statutes regarding certain board/commission appointments we would request your assistance in identifying categories that might apply to you:  


 

Please answer the following questions numbered 1 - 44.  Each question MUST BE ANSWERED.  If the answers to the question are provided on your resume, please state "See Resume".


 


 


 


 


 


































 




 




 




 




 




 




 




 




 




 


 




 




 




 




 




 

32.   Agency Proceedings and Civil Litigation of Affiliates and Family:



 




 

33.   Other Litigation:



 




 




 




 




 

37. Firings:



 




 




 




 




 




 






 




 

 

References/Significant Supporters- All fields in this section in bold are required.

REFERENCE 1


     

   

 

 

             

   

       

REFERENCE 2


     

   

 

 

             

   

       

REFERENCE 3


     

   

 

 

             

   

       

REFERENCE 4


     

   

 

 

             

   

       

 

Resume - All fields in this section in are required.

Please include a current resume.  If senate confirmation is required, a completed Statement of Substantial Interest, not more than twelve months old, must be filed.
To file an SSI:  http://www.kssos.org/elections/ssi_online.asp


 

Authorization & Certification - All fields in this section in are required.

The facts set forth in my application are true and complete. False statements, answers, or omissions on this application shall be sufficient cause for non-consideration or for dismissal after appointment or employment. I also recognize that my selection is based on receipt of satisfactory information from former employers and references, and upon my ability to perform the essential elements, with or without reasonable accommodations, for the position for which I am applying. I herein authorize investigation, without liability, of the information supplied by me in this application for employment or appointment including academic, occupational, health, law enforcement, and government records. I also authorize listed employers and references, without liability, to make full response to any inquiries in connection with this application for appointment or employment. I understand and agree that the terms, conditions, compensation, benefits, hours, schedule, and duration of my appointment or employment may be determined, changed, or modified from time to time at the will of the appointing authority or designee without limitation or condition.
I FURTHER CERTIFY THAT I HAVE READ THE FOREGOING PARAGRAPH AND KNOWINGLY MAKE THIS AUTHORIZATION BY CHECKING THE BOX BELOW.

I understand that if I am required to be registered, licensed, or certified by federal or state law or regulation for the position I seek, I will notify the appointing authority immediately if any investigation, limitation, or cancellation of my registration, licensure, or certification occurs. If any investigation, probation, limitation, or cancellation occurs, I understand that my failure to notify my appointing authority as described above will result in the termination of my appointment or employment.

Applicants must attach a bio or resume for the form to submit correctly.

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