BOARD OR COMMISSION FOR WHICH YOU ARE APPLYING *
Acupuncture Licensing Board Advanced Energy Corporation African-American Heritage Commission Aging, Governor`s Advisory Council on Agricultural & Technical State Universit Agricultural Finance Authority Agricultural Hall of Fame Agriculture and Forestry Awareness Agriculture, North Carolina State Board Alamance Community College Alarm Systems Licensing Board Alcoholic Beverage Control Commission Appalachian State University Appraisal Board Arboretum, Board of Directors Architecture, North Carolina Board of Arts Council Arts Education Arts Society Incorporated Asheville-Buncombe Technical Community Athletic Trainer Examiners Atlantic States Marine Fisheries Commiss Auctioneers Commission Awards Committee Banking Commission, North Carolina State Bar Council Barber Examiners, North Carolina State Beaufort County Community College Biofuels Center Biotechnology Center Bladen Community College Blount Street Historic District Oversigh Blue Ridge Community College Blue Ridge National Heritage Blumenthal Center for Performing Arts Boxing Advisory Commission Brain Injury Advisory Council Brunswick Community College Building Code Council Building Commission Caldwell Community College Cancer Coordination and Control - A4C Cape Fear Community College Cape Fear Navigation & Pilotage Capital Facilities Finance Agency Carteret Community College Catawba Valley Community College Catawba/Wateree River Basin Advisory Com Cemetery Commission Central Carolina Community College Central Piedmont Community College Certified Public Accountant Examiners Charter School Cherokee Preservation Foundation Child Care Commission Child Fatality Prevention Team Child Fatality Task Force Children With Special Health Care Needs Chiropractic Examiners Clean Water Management Trust Fund Cleveland Community College Coastal Carolina Community College Coastal Resources Commission Code Officials Qualification Board College Foundation, Inc. Board of Truste College of the Albemarle Board of Truste Commission for Public Health Commission for the Blind Commissioner of Banks Community Colleges, State Board Of Community Development Council Corrections Advisory Cosmetic Art Examiners Council for Women Courts Commission Craven Community College Credit Union Commission Crime Commission Crime Victims Compensation Commission Criminal Justice Education & Training Criminal Justice Information Network Data Integration Davidson County Community College Deaf and Hard of Hearing Dental Examiners Developmental Disabilities Dietetics/Nutrition Disciplinary Hearing Commission Dispute Resolution Commission Domestic Violence Durham Technical Community College East Carolina University Eastern Region ECAC - Early Childhood Economic Development Board Economic Investment Committee Edenton Historical Commission Edgecombe Community College Education Assistance Authority Education Commission of the States Education Services for Exceptional Child Education Transformation Education, State Board of eLearning Elections, North Carolina State Board of Electrical Contractors State Board of Electrolysis Examiners Elizabeth City State University Emergency Response Commission Employee Assistance Professionals - LEAP Employment Security Energy Policy Council Engineers and Surveyors Board Environmental Health Specialist Examiner Environmental Management Commission Ethics Commission Executive Mansion Fine Arts Committee Executive Mansion Fund, Inc. Board of Di Fayetteville State University Fayetteville Technical Community College Fee-Based Practicing Pastoral Film Council Financial Literacy Council Fire and Rescue Commission Firemen`s and Rescue Squad Workers` Fisheries Association, Incorporated Flue-Cured Tobacco Cooperative Food Safety and Defense Task Force Foresters, State Board of Registration Forestry Council Forsyth Technical Community College Funeral Service Gang Task Force Gasoline and Oil Inspection Board Gaston County Community College General Contractors State Licensing Boar General Statutes Commission Geographic Information Coordinating Coun Geologists, North Carolina Board Global Transpark Golden LEAF Foundation Governor Morehead School Guilford Technical Community College Halifax Community College Haywood Community College Health Coordinating Council Health Insurance Risk Pool Healthy Carolinians Hearing Aid Dealers and Fitters Heart Disease and Stroke Prevention Hispanic/Latino Affairs Historic Bath Commission Historic Hillsborough Commission Historic Murfreesboro Commission Historical Commission Historical Records Advisory Board Holocaust Council Home Inspectors Licensure Board Housing Coordination and Policy Council Housing Finance Agency Housing Partnership Human Relations Commission Humanities Council ICC Birth to Five ICC Homeless Programs Inaugural Committee Indian Affairs Indian Housing Authority Indigent Defense Services Commission Industrial Commission Inmate Grievance Resolution Board Innovation Council Internship Council Interpreter and Transliterator Licensing Interstate Adult Offender Supervision Interstate Compact Interstate Juvenile Supervision Interstate Mining Commission Interstate Oil & Gas Isothermal Community College James Sprunt Community College JOBS Study Commission John Motley Morehead Memorial Commission Johnston Community College Judicial Council Judicial Nominating Judicial Standards Commission Juvenile Justice Planning Committee Landscape Architects, North Carolina Boa Landscape Contractors Registration Board Lenoir Community College Library Commission License to Give Trust Fund Licensed Professional Counselors Local Government Commission Local Governmental Emp. Retirement Syste Locksmith Licensing Logistics Task Force Lottery Commission Lottery Oversight Committee Manufactured Housing Board Marine Fisheries Commission Marriage and Family Therapy Licensure Martin Community College Massage And Bodywork Mayland Community College McDowell Technical Community College MCNC Medical Board Medical Care Commission mental health Mental Health, DD & SAS Mid-Atlantic Fishery Management Council Military Affairs Mining Commission Minority Health Advisory Council Mitchell Community College MLK Jr. Montgomery Community College Morehead City Navigation and Pilotage Motorsports Mountain Resources Museum of Art, North Carolina Board Museum of History Associates Nash Community College Natural Heritage Trust Fund Natural Sciences Museum NC 911 Board NC Irrigation Contractors` Licensing Boa NC Thinks NCCAT NCHICA Health Care Information North Carolina Central University North Carolina South Carolina Boundary North Carolina State University Northeast Commission Nursing Home Administrators Nursing, NC Board of Occupational Safety & Health Review Occupational Therapy Offshore Wind OLF Study Group On-Site Wastewater Opticians, North Carolina State Board Of Optometry Examiners Pamlico Community College Parks and Recreation Authority Parole Commission Perfusion Advisory Committee Persian Gulf War Memorial Personnel Commission Pesticide Board Pharmacy, North Carolina Board Of Physical Therapy Examiners Piedmont Community College Pitt Community College Plant Conservation Board Plumbing, Heating and Fire Sprinkler Con Podiatry Examiners Poet Laureate Portal Project Ports Authority Principal Fellows Commission Private Protective Services Professional Advisory Committee Property Tax Commission, State Proprietary Schools Psychology Board Public Employee Deferred Compensation Public Librarian Certification Public School Forum Board of Directors Public Staff Utilities Commission Public Telecommunications Radiation Protection Railroad Board of Directors Randolph Community College Rate Bureau Real Estate Commission Recreational Therapy Licensure Refrigeration Examiners Reinsurance Facility Republic of Moldova Partnership Respiratory Care Board Revenue Oversight Richmond Community College Roanoke Chowan Regional Housing Roanoke Island Commission Roanoke Island Historical Association Roanoke River Basin Bi-State Commission Roanoke-Chowan Community College Robeson Community College Rockingham Community College Rowan-Cabarrus Community College Rules Review Commission Rural Economic Development Center Rural Electrification Authority Sampson Community College Sandhills Community College School of Science & Math, N C School Technology Science and Technology Scientific Advisory Panel on Energy Seafood and Aquaculture Seafood Industrial Park Authority SEARCH Membership Group Sedimentation Control Commission Selective Service System Sentencing and Policy Advisory Sheriffs Education and Training Sickle Cell Syndrome SILC Smart Start / Partnership for Children Social Services Commission Social Work Certification Soil and Water Conservation Commission Soil Scientists Licensing Board South Atlantic Fishery Management Counci South Piedmont Community College Southeastern Community College Southeastern Economic Development Southern Growth Policies Board Southern States Energy Board Southern Technology Council Southwestern Community College Speech and Language Pathologists and Aud SREB SREB Legislative Advisory Council SREB Legislative Work Conference Stanly Community College State Health Plan State Water Infrastructure Commission Statewide Flexible Benefits Advisory Stewardship Council Structural Pest Control Committee Substance Abuse Professionals Supplemental Retirement Surry Community College Sustainable Communities Sustainable Local Food Symphony Society Board of Trustees, N C Teacher Advisory Committee Teachers` and State Employees` Retiremen Teaching Fellows Commission Textbook Commission TIMS Tobacco Trust Fund Transportation Travel and Tourism Board Tribal Indian Gaming Compact Tri-County Community College Tryon Palace Commission Turnpike Authority U.S.S. North Carolina Battleship Umstead Act Unfair Competition Panel UNC - Asheville UNC - Chapel Hill UNC - Charlotte UNC - Greensboro UNC - Pembroke UNC - TV UNC - Wilmington UNC School of the Arts Uniform Laws Commission Utilities Commission Uwharrie Regional Recources Commission Vagabond School of Drama Board of Direct Vance-Granville Community College Veterans Affairs Veterinary Medical Board Virginia-North Carolina Interstate Compa Vocational Rehabilitation Volunteerism and Community Service Wake Technical Community College Water Treatment Certification Board Wayne Community College Well Contractors Certification Western Carolina University Western NC Public Lands Council Western North Carolina Regional Economic Western Piedmont Community College Western Residence Board of Directors Wildlife Resources Commission Wilkes Community College Wilson Community College Winston-Salem State University Workforce Development Commission Youth Accountability Youth Advisory Council Zoological Park Council
First Name *
Middle Initial
Last Name *
Prefix
County *
Home Phone #
Personal Email *
Age
Ethnicity *
- Select - White (non-Hispanic) Black (non-Hispanic) Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, other Spanish origin regardless of race) Asian (including Pacific Islander) American Indian (including Alaskan Native)
Gender *
- Select - Female Male
If yes, how long have you been a resident of NC?
Congressional District *
- Select - 1 2 3 4 5 6 7 8 9 10 11 12 13
Senate District *
- Select - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
House District *
- Select - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120
Current Employment
Spouse's Name
Spouse's Employer
Education
PROFESSIONAL LICENSE (Identify all of your professional license(s) and provide the information requested. Specify if your license is in a name other than your name listed above.)
Type of License
License #
Issuance Date
Has the license been continuously active since issuance?
REFERENCES (List three persons, not related to you, who have known you at least a year.)
1. Name *
Address *
Phone # *
2. Name *
Address *
Phone # *
3. Name *
Address *
Phone # *
Answer each question below. Additional space is provided below to explain any “Yes” answers.
CRIMINAL
PROFESSIONAL/EMPLOYMENT
TAXES
LOBBYIST
CONFLICT OF INTEREST/OTHER DISCLOSURES