Welcome! If you are interested in being considered
to serve on a board or commission, please take a
moment to answer the following questions. Certain
information is required in order to process your
message, other fields are optional, as indicated,
but will expedite handling and provide useful
information about your request.
Please note that service on these boards and commissions is
voluntary and does not include a paid salary.
Certain fields are required before the email will be sent. The form
may not submit correctly if using older web browsers. If you
experience any problems, upgrade your browser to the latest version
or go to the Contact page for
additional contact options.
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Salutation:
(Required)
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Your First Name:
(Required)
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Your Middle Name:
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Your Last Name:
(Required)
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Email Address:
(Required)
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Phone Number:
(Required, including Area Code)
(
) -
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Business Phone Number:
(
) -
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Street Address:
(Required)
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City:
(Required)
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State:
(Req)
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Zip Code:
(Req)
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Organization:
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Title:
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Full Legal Name:
(Required)
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Preferred Name:
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Date of Birth:
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Resident of Alabama:
(Required)
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Citizen of the U.S.:
(Required)
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Board(s) or
Commission(s) for which you
would like to be considered:
"Other"
selected for above, enter
the name of the Board or
Commission:
If the board for which you
are applying includes
several different positions
(e.g. general public,
licensed nurse, member of
the Alabama State bar,
etc.), please indicate the
specific position for which
you are applying.
In the box below, please use
the copy/paste function to
paste your resume:
Describe any possible
conflict of interest should
you be appointed to this
board:
Please describe any formal
charges, professional
misconduct, criminal
misdemeanor or felony ever
filed against you in any
jurisdiction:
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The following questions are
designed to elicit
information that will be
used to assure that there is
maximum diversity in the
appointments that are made.
Please note that some boards
and commissions require
specific representation such
as bipartisan representation
or disabled representation.
These questions are designed
to assist the Administration
in meeting such
requirements.
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Race/Ethnicity:
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Marital Status:
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Gender:
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Do you have any handicapping
or disabling conditions?
If YES, please explain:
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Below is a filter for SPAM messaging. You will need to
type the two words shown into the text box below in order to
submit your email.
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