New Mexico Boards & Commissions Request - Office of the Governor

We’d love to hear from you. Tell us what you need and we’ll get back to you as soon as possible.

Personal Information

Your full name — First

Your full name — Last

Have you ever used a different name for school or employment? If so, please list the name(s) here.

Address — Street Address

Address — Address Line 2

Address — City

Address — State / Province / Region

Address — ZIP / Postal Code

Address — Country

Phone

What racial or ethnic group(s) best describe you?

African AmericanCaucasianNative AmericanHispanicAsianOther

Date of Birth

Marital status

Residency & Voting

Are you a New Mexico resident?

Are you a registered voter?

Specific Board/Commission you are applying for

Other (Board/Commission you are applying for)

Explain why you are interested in serving on this board/commission

Political Background

Are you related to an employee of the State Agency that oversees this board/commission

What choice best fits your political affiliation?

Have you changed your political party designation in the past 180 days?

Have you ever been a candidate for any local, state, or federal political office?

Have you ever been appointed to any paid or unpaid local, state, or federal position?

Legal & Financial Disclosures

Do you have any financial or other interests that might present a conflict of interest if you were to be appointed to the position for which you have applied? If yes, please explain in the space below

Have you ever received payment as a lobbyist or legislative agent?

Have you ever been found guilty of any criminal law or a traffic violation for which you were fined more than $100?

Are you currently involved, or have you been involved in the past five (5) years in a civil suit?

Have you ever been accused of sexual harassment?

Please list all licensed professional or occupational membership affiliations

Are you currently an officer, director, partner, majority shareholder, managing member, or holder of a substantial interest in any corporation, partnership, or other business entity?

Do you, your spouse, or any business in which you or your spouse hold 10% or more of the stock or membership interest, have any relationship with any federal, state, or local governments or Indian nation?

Have you filed all federal and state tax returns that are now due or overdue?

Have all tax payments, fines, penalties, and interest been paid in full and/or otherwise settled with the taxing authority?

Has a tax lien or other collection procedure every been initiated against you or your spouse by local, state, or federal authorities?

If there are specific designated requirements related to the desired appointment (e.g. age requiremnts, professional license, or any other statutory or constitutional specification), please state how you meet the requirements

I understand that the New Mexico Open Meetings Act may require that certain information contained in the application be available for inspection by the general public.Yes, I understand

Education

Education Level

High school name

City and state of high school

Year graduated high school

References

Please provide at least 2 (up to 3) references with contact information.

Name of 1st reference: — First

Name of 1st reference: — Last

Relationship of 1st reference

Phone of 1st reference

Email of 1st reference

Name of 2nd reference: — First

Name of 2nd reference: — Last

Relationship of 2nd reference:

Phone of of 2nd reference:

Email of of 2nd reference:

Name of 3rd reference: — First

Name of 3rd reference: — Last

Relationship of 3rd reference:

Phone of of 3rd reference:

Email of of 3rd reference:

Background Check & Certification

Have you ever served on active duty in the United States Armed Forces, Military Reserves, or National Guard

I agree to the following:Email Governor.BCD@exec.nm.gov your most recent resume at your earliest convenience. By selecting this checkbox, I acknowledge that failure to do so may delay or disqualify my application.

Do you have a valid New Mexico driver's license?

Last four digits of your SSN

I hereby certify that:This request contains no willful misrepresentation(s).

I understand that:Should any investigation disclose such misrepresentation or falsification, my application will be rejected, my name removed from consideration for appointment, or I may be removed from appointment.

I understand that:Submission of my request does not guarantee appointment. I understand that I may be required to submit to a background check as a condition of appointment.

I understand that:Unsatisfactory results from, refusal to cooperate with, or any attempt to affect the result of these background checks will result in withdrawal of any offer or termination of appointment.

Signature (type your full legal name)

Today's Date

New Mexico Boards & Commissions Request for Appointment