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Minnesota Office of the Secretary of State

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Open Appointments Application
State of Minnesota

All information on this form is available to the public upon request.
By request, this application will be made available in alternative format (Braille, large print, audio tape, etc.)

1. Today's Date:

Part 1: Position Sought
Required information (MN Stat § 15.0597 Subd. 5.)

2. Agency Name: (Name of board, council, commission or task force)
3. Position Sought: (Membership position sought or enter "member")

Part II: Applicant Information
Required Information (MN Stat §15.0597 Subd. 5)

4. First Name:

5. Last Name:

6. Mailing Address:

7. City:

8. State:

9. Zip Code:

10. Phone:

11. Email:

12. County:

13. MN House of Representatives District:
Find your districts by using the Poll Finder at:

14. US House of Representatives District:
Find your districts by using the Poll Finder at:

15. Did the Appointing Authority suggest that you submit an application?
16. Have you ever been convicted of a felony:
Include a cover letter, resume or other information that you feel would be helpful to the Appointing Authority.
17. Cover Letter or other information helpful to the appointing authority:

18. 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.

19. Gender
20. Disability:
21. Age:

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

24. Hispanic, Latino, or Spanish Origin?
25. Race:
Pick as many as apply.
26. 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.
(*If another person or group is nominating the applicant, the applicant's signature indicates consent to nomination.)

27. Applicantl Name:

28. Date:

29. Questions?

Telephone Number: 651-556-0643

E-Mail Address:

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)

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