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 certain fields are required before the email will be
sent.
Please note that 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:
(Required:
Street Address, City, State)
NOTE: to select more than one organization hold down Control key when clicking.
"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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