Application for Boards and Commissions N. C.

House of Representatives
Office of Speaker Thom Tillis
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 No
%oter&
Are you a resident of NC' $es No If yes( ho) lon ha*e you +een a resident of NC'
Present Employer,-""upation .o+ /itle
0usiness Address City State Zip
0usiness Phone # 0usiness Email
Cell Phone # Corresponden"e Preferen"e& Home 0usiness
Spouse1s Name Spouse1s Employer
EDUCATION HISTORY 2Spe"ify s"hool attended( year of raduation and type of deree re"ei*ed( if any3
Hih S"hool,E4ui*alen"e 256E6!63
7nderraduate
5raduate,Professional
PROFESSIONAL LICENSE 2Identify all of your professional li"ense2s3 and pro*ide the information re4uested6 Spe"ify if your
li"ense is in a name other than your name listed a+o*e63
/ype of Li"ense Li"ense # Issuan"e !ate Has the li"ense +een "ontinuously
a"ti*e sin"e issuan"e'
REFERENCES 2List three persons( not related to you( )ho ha*e 8no)n you at least a year63
NAME A!!#ESS PH-NE #
PUBLIC OFFICIAL/OFFICES 2List all appointed or ele"ted positions you "urrently hold on any +oard( "ommission( "oun"il(
authority or other entity "reated +y lo"al( state or federal o*ernment63
Answer each !es"#$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 Ha*e you e*er +een "hared )ith a misdemeanor( other than a traffi" offense( in
North Carolina or else)here'
$es::::: No:::::
=6 Ha*e you e*er +een "on*i"ted of a misdemeanor( other than a traffi" offense( 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 that
reulates 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 professional
li"ense'
$es::::: No:::::
A6 Ha*e you( or any +usiness in )hi"h you o)n a "ontrollin interest( e*er +een fined or
other)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
9C6 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 the
last year( or ha*e you employed a reistered lo++yist in the last year'
$es::::: No:::::
CONFLICT OF INTEREST/OTHER DISCLOSURES
9<6 Are you or your spouse reulated +y( li"ensed +y( or enaed in a +usiness
relationship )ith the +oard to )hi"h you are see8in appointment'
$es::::: No:::::
9=6 !o you ha*e any finan"ial interest in any "ompany that does +usiness )ith the State
of North Carolina'
$es::::: No:::::
9>6 Are you( or any entity in )hi"h you ha*e a finan"ial or other interest( the re"ipient of
any 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 the
House 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 release
all parties from all lia+ility for any damae that may result from furnishin su"h information6 I understand that
failure to fill out this form a""urately and truthfully shall su+De"t me to immediate remo*al6
SI5NA/7#E ::::::::::::::::::::::::::::::::::::::::::::::::!A/E ::::::::::::::::::
#eturn "ompleted form to& -ffi"e of the Spea8erE Attn& 0oards and CommissionsE 9? Fest .ones Street( Leislati*e
0uildin Suite ;<C@E #aleih( NC ;@?C9G9CB?( *ia fax to 2B9B3 @9>GC@@;( or email to .ulie6LisellaHn"le6net

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