State of Delaware Office of the Governor Board and Commission Application Ruth Ann Minner Governor  
Name:  First  Middle Initial  Last 
 
Date of Birth  
Address:  
 

Street DE

City Telephone: Residence 
 Business  State  Zip 
 County Fax: 
 
SS#: 
 Political Affiliation:  
 
Education:  
 


Employment Experience: 



Please list those areas of interest or expertise in which you would like to participate as a member on a board or commission 


If you wish to apply for an appointment to a particular board or commission, please 
indicate the number of desired board below. (see attached listing of all active boards and 
commissions) Application 
 
 
Page Two 
Are you only interested in a paid appointment?YES 


NO
OffOff
Required Compensation:


How much time are you willing to commit to a voluntary, non-paid position? 


What Special skills could you bring to a board or commission? 

List all current organizations and societies of which you are a member. 



Do you hold any professional licenses? Please specify: 

Have you ever been convicted of a misdemeanor within the past five years or a felony within the past ten years? 
YES 

NO 

If “YES”, explain the circumstances on a separate sheet of paper and attach it to this application. A conviction is not necessarily grounds for disqualification. The number of convictions, nature, recentness, and relationship to the board position applied for will be evaluated and a determination will be made after a review of all relevant facts. OffOff


NO 

CONFLICTS OF INTEREST: Certain boards and commissions require full disclosure of personal financial data. If required for the board or commission for which you are applying, are you willing to do so? OffOff
YES Application 

Page Three 
Could you or any member of your family be affected financially by decisions to be made 
by the board or commission for which you have applied? YES 


Off
NO Off
If “YES”, explain: 


Please list any previous government appointments: 

Additional Comments: 

Signature Date 
Please return to: Office of the Governor 
Lydia Prigg 
Director Boards and Commissions 
Tatnall Building, 2nd Floor 
Dover, DE 19901 
Telephone: 302-744-4101 Fax: 302-739-2775