General Information
Prefix
* First Name
MI
* Last Name
Suffix
* Address Line 1
Address Line 2
* City
* State
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Tennessee
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Utah
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Washington
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* Zip
Phone
Work Phone
Cell Phone
* Email
Board/Commission to which you are seeking appointment.
*optometry*
911 Coordinating Council
Abstracters Board of Examiners
Acupuncture Advisory Council
Adjutant General
Advantage Kansas Coordinating Council
Advantage Kansas Coordinating Council
Advantage Kansas Coordinating Council
Advantage Kansas Coordinating Council
Advantage Kansas Coordinating Council
Advantage Kansas Coordinating Council
Advantage Kansas Coordinating Council
Advantage Kansas Coordinating Council
Advisory Commission for Children With Special Health Care Needs
Advisory Committee on Regulation of Oil and Gas Activities
Advisory Council on Aging
Athletic Commission
Athletic Trainers Council
Behavioral Sciences Regulatory Board
Board of Accountancy
Board of Adult Care Home Administrators
Board of Barbering
Board of Examiners in Optometry
Board of Nursing
Board of Pharmacy
Brigadier General of the Kansas National Guard
Capitol Area Plaza Authority
Capitol Preservation Committee
Central Interstate Low-Level Radioactive Waste Commission
Children and Families
Citizens' Utility Ratepayer Board
Commission on Autism
Commission on Emergency Planning and Response (CERP)
Coordinating Council on Early Childhood Developmental Services
Council on Travel and Tourism
Court of Appeals Nominating Commission
Creative Arts Industries Commission
Cybersecurity Task Force
Delta Dental of Kansas Board of Directors
Education Commission of the States
Electronic Recording Commission
Emergency Medical Services Board
Employment Security Board of Review
Fire Service Training Commission
Future of Higher Education Council
Governmental Ethics Commission
Governor's Behavioral Health Services Planning Council
Governor's Commission on Racial Equity and Justice
Governor's Council on Education
Governor's Council on Tax Reform
Governor's KanCare Advisory Council
INACTIVE - State Use Law Committee
INACTIVE Nursing
Information Network of Kansas
Information Technology Executive Council (ITEC)
Interagency Working Group for Wind Energy
Interstate Adult Offender Supervision Council
Interstate Compact on Educational Opportunity for Military Children Council
Interstate Medical Licensure Compact
Interstate Oil and Gas Compact Commission
James B. Pearson Fellowship Selection Board
Johnson County Education Research Triangle Authority
Kansas Advisory Committee for the Blind and Visually Impaired
Kansas Advisory Group on Juvenile Justice and Delinquency Prevention
Kansas African American Affairs Commission (KAAAC)
Kansas Agricultural Remediation Board
Kansas Alzheimer's Disease Task Force
Kansas Animal Health Board
Kansas Bar Foundation IOLTA Committee
Kansas Board of Examiners in Fitting and Dispensing of Hearing Instruments
Kansas Board of Regents
Kansas Business Health Policy Committee
Kansas Children’s Cabinet
Kansas Commission for the Deaf and Hard of Hearing
Kansas Commission on Disability Concerns
Kansas Commission on Peace Officers' Standards and Training
Kansas Corporation Commission
Kansas Council for Interstate Adult Offender Supervision
Kansas Council on Developmental Disabilities
Kansas Credit Union Council
Kansas Criminal Justice Coordinating Council
Kansas Criminal Justice Reform Commission
Kansas Dealer Review Board
Kansas Dental Board
Kansas Development Finance Authority
Kansas Employment First Oversight Commission
Kansas Firefighters Memorial Advisory Committee
Kansas Guardianship Program Board of Directors
Kansas Hispanic and Latino American Affairs Commission
Kansas Historical Records Advisory Board
Kansas Human Rights Commission
Kansas Humanities Council
Kansas Juvenile Justice Oversight Committee
Kansas Lottery Commission
Kansas Military Advisory Board
Kansas Military Disability Board
Kansas Pet Animal Advisory Board
Kansas Propane Education and Research Council
Kansas Public Employees' Retirement System Board of Trustees
Kansas Quality Care Improvement Panel
Kansas Racing and Gaming Commission
Kansas Real Estate Commission
Kansas Sentencing Commission
Kansas Sports Hall of Fame Board of Trustees
Kansas State Board of Cosmetology
Kansas State Fair Board
Kansas State High School Activities Association
Kansas State Historical Society, Inc. Executive Committee
Kansas Statewide Independent Living Council
Kansas Turnpike Authority
Kansas Volunteer Commission
Kansas Water Authority
Kansas Wildlife, Parks and Tourism Commission
Kansas-Colorado Arkansas River Compact Commission
Kansas-Missouri Metropolitan Culture Commission
Kansas-Nebraska Big Blue River Interstate Compact
Kansas-Oklahoma Arkansas River Compact Commission
KANSASWORKS State Board
Law Enforcement Officers Memorial Advisory Committee
Lottery Gaming Facility Review Board (2014-2015)
Masonic Cancer Alliance Partners Advisory Board
Mid-Continent Comprehensive Center (MC3) Advisory Board
Midwest Interstate Passenger Rail Commission
Midwest Stem Cell Therapy Center Advisory Board
Midwestern Higher Education Compact
Midwestern Radioactive Materials Transportation Committee
Military Children Educational Council
Missouri River Association of States and Tribes (MoRAST)
Missouri River Ecosystem Restoration Plan (MRERP)
Missouri River Recovery Implementation Committee
Naturopathic Advisory Council
Occupational Therapist Council
Partnership Historic Site Committee
Persian Gulf War Veterans Health Initiative Board
Physical Therapy Advisory Council
Physician Assistant Council
Physician Workforce and Accreditation Task Force
Pooled Money Investment Board
Postsecondary Technical Education Authority
Public Employee Relations Board
Public Finance Transparency Board
Radiologic Technology Council
REACH Healthcare Foundation Community Advisory Committee
Real Estate Appraisal Board
Respiratory Care Council
Secretary of Administration
Secretary of Aging and Disability Services
Secretary of Agriculture
Secretary of Commerce
Secretary of Corrections
Secretary of Health and Environment
Secretary of Labor
Secretary of Revenue
Secretary of Transportation
Selective Service System
Senior Care Task Force
Solid Waste Grants Advisory Committee
State Banking Board
State Board of Agriculture
State Board of Healing Arts
State Board of Indigents Defense Services
State Board of Mortuary Arts
State Board of Tax Appeals
State Board of Technical Professions
State Board of Veterinary Examiners
State Building Advisory Commission
State Civil Service Board
State Employee Health Care Commission
State Historic Sites Board of Review
State Holocaust Commission
State Library of Kansas Board
State Long-Term Care Ombudsman
State Rehabilitation Council
State Use Law Committee
Superintendent of the Highway Patrol
Supreme Court Nominating Commission
Unemployment Compensation Modernization and Improvement Council
University of Kansas Hospital Authority
Unmarked Burial Sites Preservation Board
Veterans Claims Assistance Program (VCAP) Advisory Board
Washburn University Board of Regents
Western Governor's Wildlife Council
Western Invasive Species Council of the Western Governors' Association
Western States Water Council
Wichita State University Board of Trustees
Workers Compensation and Employment Security Boards Nominating Committee
*
I am open to any Board/Commission to which my skills and experience would be suited
I am only interested in the Board/Commission I selected above
Note: If you are retired, please enter 'retired' in the Employer Business Name field and list your home address and the last position/title held when you were employed.
* Employer Business Name
* Business Address
* City
* State
* Zip
* Position/Title
* Date of Birth (mm/dd/yyyy)
* Race/Ethnicity Identification
White, not Hispanic
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Hispanic or Latino
Two or more races
Other
Prefer not to say
* Gender Identification
Female
Male
Non-Binary
Other
Prefer not to say
* Are you an individual with a disability?
Yes
No
Prefer not to say
* Are you the parent/guardian of an individual with a disability?
Yes
No
Prefer not to say
Are you a member of the LGBTQ community?
Yes
No
Prefer not to say
* Kansas Resident?
Yes
No
Registered Voter?
Yes
No
* Party Afilliation
Democrat
Independent
Libertarian
Republican
Unaffiliated
Nonregistered
* Congressional District
1st
2nd
3rd
4th
To assist you in finding your State Senate District Number or State Representative District Number you can go to: https://openstates.org/
* KS State Senate District
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
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14th
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27th
28th
29th
30th
31st
32nd
33rd
34th
35th
36th
37th
38th
39th
40th
* KS State Representative District
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
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101st
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111th
112th
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120th
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123rd
124th
125th
* Do you have any social media accounts?
Yes
No
If yes, please list the account(s) and username.
* 1. What is your educational background? (Please list degree, major course, school and dates)
* 2. List any professional licenses that you have obtained and include the number for each license.
* 3. Why do you feel you are a good candidate for the position to which you are seeking appointment?
4. Military Service: Do you have any military experience?
Yes
No
If YES, list branch, rank, dates and type of discharge from active service
Authorization & Certification - All fields in this section in are required. The facts set forth in my application are true and complete. False statements, answers, or omissions on this application shall be sufficient cause for non-consideration or for dismissal after appointment or employment.
I also recognize that my selection is based on receipt of satisfactory information from former employers and references, and upon my ability to perform the essential elements, with or without reasonable accommodations, for the position for which I am applying.
I herein authorize investigation, without liability, of the information supplied by me in this application for employment or appointment including academic, occupational, health, law enforcement, and government records. I also authorize listed employers and references, without liability, to make full response to any inquiries in connection with this application for appointment or employment. I understand and agree that the terms, conditions, compensation, benefits, hours, schedule, and duration of my appointment or employment may be determined, changed, or modified from time to time at the will of the appointing authority or designee without limitation or condition.
I FURTHER CERTIFY THAT I HAVE READ THE FOREGOING PARAGRAPH AND KNOWINGLY MAKE THIS AUTHORIZATION BY CLICKING THE SUBMIT BUTTON BELOW.
I understand that if I am required to be registered, licensed, or certified by federal or state law or regulation for the position I seek, I will notify the appointing authority immediately if any investigation, limitation, or cancellation of my registration, licensure, or certification occurs. If any investigation, probation, limitation, or cancellation occurs, I understand that my failure to notify my appointing authority as described above will result in the termination of my appointment or employment. By clicking the submit button, I declare under penalty of perjury that I am the person named above, and the foregoing information is true and correct.
* 5. Elective Public Office: Have you ever held a public office?
Yes
No
If YES, list all elective public offices sought and/or held with dates of service.
6. Miscellaneous: Other than the information provided thus far, are there any other factors which particularly qualify you or are relevant to the position to which you are seeking appointment?
Yes
No
If YES, please list. Include any special skills.
References/Significant Supporters
Prefix
* First Name
MI
* Last Name
Suffix
Title
Organization
* Address Line 1
Address Line 2
* City
* State
Alabama
Alaska
America Samoa
Arizona
Arkansas
California
Colorado
Connecticut
D.C.
D.C.
Delaware
Federated States of Micronesia
Florida
Foreign Correspondence
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Trust Territory
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip
Phone
Work Phone
* Email
Resume
* Please attach an electronic copy of your resume. (Word or PDF format only)
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