Minnesota Office of the Secretary of State : Complete a Survey

Survey/Form Review

Open Appointments Application

State of Minnesota
OPEN APPOINTMENTS APPLICATION FOR SERVICE ON
STATE AGENCIES, BOARDS, COUNCILS, COMMISSIONS or TASK FORCES.
All information on this form is available to the public upon request.

1. Today's Date:

Part 1 - Tell us about the position to which you are applying
Required information (MN Stat 15.0597 Subd. 5.)

2. Agency Name: ("Agency" is the name of the Board, Council, Commission or Task Force to which you are applying.)

3. Position Sought: (Name of position sought, or enter "member")

Part II - Tell Us About Yourself
Required Information (MN Stat 15.0597 Subd. 5)

4. Applicant First Name:

5. Applicant Last Name:

6. Preferred Mailing Address:

7. Mailing Address:

8. City

9. State:

10. Zip Code:

11. Preferred Telephone Number:

12. E-Mail Address:

13. County Name:

14. Minnesota House of Representatives District Number:
Find your districts by using the Poll Finder at: http://pollfinder.sos.state.mn.us

15. United States House of Representatives District Number:
Find your districts by using the Poll Finder at: http://pollfinder.sos.state.mn.us

16. Did the Appointing Authority suggest that you submit an application?

17. Have you ever been convicted of a felony:

You may also submit information that you feel would be helpful to the Appointing Authority.
(M.S. 15.0597 Subd. 5.)

Items you might include:
- Cover Letter - demonstrating your interest and qualifications to the Appointing Authority;
- Current Resume;
- Other helpful information.

18. Cover Letter or other information helpful to the appointing authority:

19. Resume or other information helpful to the appointing authority:

Part III: Optional Statistical Information
The following information is optional and voluntary (MN Stat 15.0597 Subd. 5.).
Information is collected for, and compiled in, the annual report on the open appointments process pursuant to MN Stat 15.0597 Subd. 7.

20. Sex

21. Disability:

22. Age:

23. Political Party:

24. If you answered "Other" for Political Party, please state name of Political Party or Political Affiliation:

25. Hispanic, Latino, or Spanish Origin?

26. Race:
Pick as many as apply.

African American or Black

American Indian or Alaska Native

Asian or Pacific Islander

White or Caucasian

Other Race

27. If you answered Other Race, please specify.

Part IV: Signature and Submittal Instructions

I swear that, to the best of my knowledge, the above information is correct and that I satisfy all legally prescribed qualifications for the position sought.

28. Full Name:

29. Application Date:

30. Questions?

Telephone Number: 651-556-0643

E-Mail Address: open.appointments@state.mn.us

The Appointing Authority will contact you directly if additional information is required, or if an interview is desired.

Agency Name (Note: no action required by applicant)

Page 1 / 1