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Get Biographical Information Form

OFFICE OF THE GOVERNOR REQUEST FOR APPOINTMENT CONSIDERATION BIOGRAPHICAL INFORMATION FORM Please state below the board or commission or general subject area in which you have an interest Application for New Appointment Name Date of Birth US Citizen Race Gender MD resident since Registered Voter Ethnic/gender data is solely to assure diversity in representation Home Address City State Zip Resident County MD Legislative District MD Congressional District Council or Commission District Occupation Employer Work Address Phones Office Home Cell Fax Email Address Sponsoring Organization If Any Have you ever been a party plaintiff or petitioner/defendant or respondent to any civil criminal juvenile or administrative proceeding No Yes Specify Do you hold a Maryland license to practice a profession or trade Yes If yes specify License Have you ever had a license to practice a profession or trade whether held in Maryland or another state revoked or suspended Are you a member officer or director of any organization Specify Organization or Activity If so are you engaged in any lobbying activities for that organization Are you a paid lobbyist for any organization If so please specify the organization Do you hold or have you held in the past an elected or appointed office within Federal State or local government or a political party Specify Office Specify Dates Have you filed all Federal and State tax returns that are now due or overdue and are all payments thereupon up to date No Explain Have Federal State or local authorities ever instituted a lien or other collection procedures against you Yes Explain List the names business addresses and business telephone numbers of at least 2 individuals who are familiar with your professional qualifications and who have known you for more than the last five years Please attach a resume that includes information concerning your academic background work experience and professional political and civic organization affiliations. If a resume is not available please supply requested information in spaces provided below. ACADEMIC BACKGROUND WORK EXPERIENCE ORGANIZATIONAL AFFILIATIONS I certify that to the best of my knowledge and belief all the information contained in and attached to this questionnaire is true correct and complete. I understand and agree that I am required to notify the Office of the Governor in writing if any of the information contained in or attached to this questionnaire changes. Signature of applicant Date Completed forms may be returned to Anna Lieberman Administrator Office of Appointment and Executive Nominations 201 W* Preston Street Baltimore MD 21201 Phone 410 767-4049 Fax 410 333-7687 Email alieberman dhmh. If a resume is not available please supply requested information in spaces provided below. ACADEMIC BACKGROUND WORK EXPERIENCE ORGANIZATIONAL AFFILIATIONS I certify that to the best of my knowledge and belief all the information contained in and attached to this questionnaire is true correct and complete. I understand and agree that I am required to notify the Office of the Governor in writing if any of the information contained in or attached to this questionnaire changes.

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