7/27/2019 B&CApplication NC COMMON CORE COMMISSION

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Application for Boards and Commissions N. C. House of Representativ

Office of Speaker Thom Ti

BOARD OR COMMISSION FOR WHICH YOU ARE APPLYING:

First Name MI Last Name Prefix

Home Address City State Zip

County Home Phone # Personal Email

Conressional !istri"t Senate !istri"t House !istri"t eistered $es N%oter&

Are you a resident of NC' $es No If yes( ho) lon ha*e you +een a resident of NC'

Present Employer,-""upation .o+ /itle

0usiness Address City State Zip

0usiness Phone # 0usiness Email

Cell Phone # Corresponden"e Preferen"e& Home 0usiness

Spouse1s Name Spouse1s Employer

EDUCATION HISTORY2Spe"ify s"hool attended( year of raduation and type of deree re"ei*ed( if any3

Hih S"hool,E4ui*alen"e 256E6!63

7nderraduate

5raduate,Professional

PROFESSIONAL LICENSE2Identify all of your professional li"ense2s3 and pro*ide the information re4uested6 Spe"ify if yourli"ense is in a name other than your name listed a+o*e63

/ype of Li"ense Li"ense # Issuan"e !ate Has the li"ense +een "ontinuous

a"ti*e sin"e issuan"e'

REFERENCES 2List three persons( not related to you( )ho ha*e 8no)n you at least a year63

NAME A!!ESS PH-NE #

PUBLIC OFFICIAL/OFFICES2List all appointed or ele"ted positions you "urrently hold on any +oard( "ommission( "oun"il(authority or other entity "reated +y lo"al( state or federal o*ernment63

7/27/2019 B&CApplication NC COMMON CORE COMMISSION

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Answer each !es"#$n %e&$w' P&ease a""ach an a((#"#$na& shee")s* "$ e+,&a#n an- .Yes answers'

CRIMINAL

96 Ha*e you e*er +een "hared )ith a felony in North Carolina or else)here' $es::::: No:::::

;6 Ha*e you e*er +een "on*i"ted of a felony in North Carolina or else)here' $es::::: No:::::

6 Has your dri*er1s li"ense e*er +een suspended( re*o8ed( or limited' $es::::: No:::::

PROFESSIONAL/EMPLOYMENT

?6 Ha*e you e*er had any rie*an"e or "omplaint filed aainst you )ith any +oard thatreulates your professional li"ense2s3 or had a professional li"ense suspended(re*o8ed or modified'

$es::::: No:::::

@6 Ha*e you e*er had any san"tion or reprimand entered aainst your professionalli"ense'

$es::::: No:::::

6 Ha*e you( or any +usiness in )hi"h you o)n a "ontrollin interest( e*er +een fined orother)ise san"tioned +y a lo"al( state or federal aen"y'

$es::::: No:::::

B6 Ha*e you e*er +een dis"iplined +y the +oard to )hi"h you see8 appointment' $es::::: No:::::

TA0ES

96 Ha*e you e*er failed to file state or federal in"ome tax returns' $es::::: No:::::

996 Are you( or any "ompany in )hi"h you or your spouse has a "ontrollin interest(delin4uent in payin any lo"al( state or federal taxes'

$es::::: No:::::

LOBBYIST

9;6 Are you "urrently a reistered lo++yist( ha*e you +een a reistered lo++yist in thelast year( or ha*e you employed a reistered lo++yist in the last year'

$es::::: No:::::

CONFLICT OF INTEREST/OTHER DISCLOSURES

96 Are you( or any entity in )hi"h you ha*e a finan"ial or other interest( the re"ipient ofany rant or appropriation from the State of North Carolina'

$es::::: No:::::

9?6 Are you a)are of any other information that )ould +e rele*ant for the Spea8er of theHouse to 8no) as he "onsiders appointin you to a +oard or "ommission'

$es::::: No:::::

I "ertify that the fa"ts "ontained in this appli"ation are true and "orre"t to the +est of my 8no)lede6 I releaseall parties from all lia+ility for any damae that may result from furnishin su"h information6 I understand thatfailure to fill out this form a""urately and truthfully shall su+De"t me to immediate remo*al6

SI5NA/7E ::::::::::::::::::::::::::::::::::::::::::::::::!A/E ::::::::::::::::::

eturn "ompleted form to& -ffi"e of the Spea8er Attn& 0oards and Commissions 9? est .ones Street( Leislati*e0uildin Suite ;G@@;( or email to .ulie6Lisellan"le6net