GOVERNOR GREG ABBOTT
OFFICE OF THE GOVERNOR
APPOINTMENT APPLICATION

1.	Personal Information					 	2.  Photograph
Full Legal Name      	
 	
Preferred Name       		
Spouse’s Name       		
Physical Home Address           		
City, State  Zip       ,            		
Mailing Address        		
City, State  Zip      ,            		
County
     	Work Telephone
   -   -     	Home Telephone
   -   -     		
Cellular
   -   -     	Preferred E-mail Address
     	State Senator
     	
Secondary E-Mail Address (if applicable)
     	State Representative
     	

3.  State Board(s), Commission(s), or Task Force(s) of Interest to You:
The list of all entities to which the Governor makes appointments may be found at: http://www.gov.texas.gov/appointments/positions

     	     	
     	     	
     	     	
     	     	
     	     	

4.  Employment Information
Employer
     	Employer’s Address
     
     
     	Present Job Title
     	
		Profession
     	
Present Job Description
     

Name        	

5.  Education/Training
Type of School	Name and Location of School	Year Graduated	Degree and
Field of Study	
High School	     	     	     	
Undergraduate	     	     	     	
Graduate	     	     	     	
Other	     	     	     	

6.  Employment History
Employer	Position	Dates	Location	
     	     	     	     	
     		     	     	     	
     	     	     	     	
     	     	     	     	

7.  References
Name	Employer	City	Telephone	Relationship	
     	     	     	   -   -     	     	
     	     	     	   -   -     	     	
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8.  Professional Memberships (including any state bar memberships)
Organization	Title/Position	Current/Former	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

9.  Volunteer Participation 
Organization	Title/Position	Current/Former	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

10.  Military Service
Are you or have you ever been a member of the Armed Forces of the United States:                 Yes     No	
Branch	Dates of Service	Type of Discharge	
     	     	     	
     	     	     	

Name        	

11.  Social Media Information 
Do you use, or have you ever used, any of the following?  If “yes,” provide additional information.	
Facebook 	 Yes    No	Username       	
Twitter 	 Yes    No	Handle @     	
Instagram 	 Yes    No	Username       	
LinkedIn 	 Yes    No	Profile       	
Google+	 Yes    No	Username       	

12.  Spouse Information	 This Section Not Applicable
Spouse’s Employer
     	Job Title/Position
     	
Does your spouse conduct any business with or before the Texas Legislature or any other state entity?    Yes    No	If yes, please list agencies:
     	

13.  Miscellaneous Information
Note: “Material interest” is defined as (a) serving on the governing board of directors or (b) a ten (10) percent or greater ownership.  This does not apply to any mutual funds in which you do not exercise authority in investment decisions.
Have you filed federal income tax returns for the past five (5) years?  If no, give details.	 Yes   No	
     

Are you, your spouse, or any company in which you have a material interest currently delinquent in any local, state or federal taxes?  If yes, give details.	 Yes   No	
     	
Have you ever defaulted on a personal, business or student loan?  If yes, give details.	 Yes   No	
Type of Loan	Date	Details	
     	     	     	
     	     	     	

Have you, your spouse, or any company in which you have a material interest or of which you have been an officer or principal been involved in any bankruptcy proceeding?  If yes, give details including dates.	 Yes   No	
     	

Do you currently serve, or have you ever served, on any local, state or federal government board, commission or committee or in any elected or appointed office?	 Yes   No	
Entity	Position	Dates	Compensated 
(Y/N)	Reimbursed
(Y/N)	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	

Name        	

13.  Miscellaneous Information (Continued)
Are you or your spouse related to a local, state, or federal public official?	 Yes   No	
Name of Official and Title	Relationship	
     	     	
     	     	
     	     	
     	     	

Do you or your spouse have any material interest in, or are either of you employed by, any company that does business with or receives funds from the State of Texas?
If yes, give full name and details:	 Yes   No	
Name of Company	Details	
     	     	
     

	     	
Are you or your spouse an officer, director, employee or paid consultant of a trade association?                    Yes    No                  

 If yes, please list association and position:      
                      	Self
     
	
	Spouse
     

Have you or your spouse ever been registered as a lobbyist or received compensation to represent someone before a local, state, or federal government?	 Yes   No	
Self or
Spouse	Entity Represented	Entity Lobbied	Dates	
     	     	     	     	
     	     	     	     	
     	     	     	     	

Have you, your spouse, or any company in which you or your spouse have a material interest been party to litigation? If yes, give details.	 Yes   No	
     

In the last five years, have you, or any company in which you have a material interest, been licensed by a Texas state agency?  If yes, give details.	 Yes   No	
Agency	Type of License	License #	Expiration	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	

Have you ever been delinquent in child support payments?  If yes, give details.	 Yes   No
  Not Applicable	
     		

Name        	

13. Miscellaneous Information (Continued)

To the best of your knowledge, has any federal, state or local law enforcement or regulatory agency (on behalf of itself or any other person or entity) filed or investigated any grievance or complaint against you, your spouse, or an entity in which you have a material interest?  If yes, give details and disposition (investigated, dismissed, reprimanded)	 Yes   No	
Agency	Date	Details and Disposition	
     	     	     	
     	     	     	

To the best of your knowledge, have you, your spouse, or any company in which you have a material interest been investigated, reprimanded, fined or suspended from doing business with any state or federal agency?  If yes, give details and disposition (investigated, reprimanded, fined, suspended)	 Yes   No	
Agency	Date	Details and Disposition	
     	     	     	
     	     	     	

Have you ever been convicted in a criminal proceeding (excluding traffic violations), placed on probation, required to perform community service, or had a criminal proceeding disposed of by pre-trial diversion, deferred prosecution, deferred adjudication, or some similar proceeding?
 
If yes, list the charge, the date of the offense, the city and/or county and state in which it allegedly occurred, and the disposition thereof.	 Yes   No	
     

	

14.  Certification

Full Legal Name        
	
Date of Birth     /     /     	Texas Driver License or DPS ID#       	
Are you a U.S. Citizen?  Yes   No	Place of Birth       	
Date of naturalization (if not a citizen upon birth)         /     /     	
Ethnicity:  (optional; check all that apply)         White                           African American

              Hispanic         Asian American      Native American        Other	

Notes:  
•	Appointment to a Board or Commission may require the annual filing of a Personal Financial Statement (PFS) Form with the Texas Ethics Commission.

•	A resume must be attached in order for this application to be considered complete.

•	Judicial candidates must also complete a Judicial Questionnaire.

•	Any information provided on the application or attached may be subject to the Texas Public Information Act. This means that an individual requesting copies of the information in your file may be provided access to that information.

CERTIFICATION OF APPLICANT

I hereby certify that the foregoing and any attached statements are true, accurate and complete.  I agree that any misstatement, misrepresentation, or omission of a fact may result in my disqualification for appointment.  I assign and hereby give the Office of the Governor full authority to conduct background investigations pertinent to this application.  I specifically authorize the Texas Department of Public Safety to conduct a background investigation and to disclose the results of that investigation to the Governor or his authorized representative.
	
																			__________________________
							Applicant’s Signature

	     
							__________________________
Submit to:						Date

Appointments Staff	(512) 463-1828  
Office of the Governor	(512) 475-2576 fax
PO Box 12428	www.gov.texas.gov
Austin, Texas  78711 	

ServingTexas@gov.texas.gov (with scanned signature page)