Board Applicant ID#
Driver's License / Kansas ID #
Social Security #
This information will not be made public but is used by the KBI and the Department of Revenue.
Place of Birth
Do you have the legal right to live and work in the United States?
Yes
No
In order to ensure that we are in compliance with statutes regarding certain boards/commissions appointments, we would request your assistance in identifying categories that might apply to you:
If you are seeking an appointment to the Kansas Commission on Disability Concerns (K.S.A. 74-6702) or the State Council on Developmental Disabilities (K.S.A. 74-5501), please specify your disability if any:
Are you the Parent/Guardian of an individual with a disability? (K.S.A. 74-5501)
Yes
No
Ethnic/Cultural Background: (This information is optional. Under State and Federal Law this information may not be used to discriminate against you.)
6. Describe your employment experience. Include any expertise related to the position to which you are seeking appointment.
7. What do you see as the purpose or mission of the role to which you are seeking appointment?
8. Government Experience: Do you have any government experience?
Yes
No
If Yes, list any experience or associations with local, state, or federal government (exclusive of elected public office, but including advisory, consulting, honorary, appointed, or other part-time service or positions); included dates of service.
9. Campaigns: Have you ever played a role or held a position in a political campaign?
Yes
No
If YES, please identify the candidate(s), the dates of the campaign and describe your involvement.
10. Honors and Awards: Have your received any honors or awards?
Yes
No
If YES, list all scholarships, fellowships, honorary degrees, honorary society memberships, and any other special recognition for outstanding service or achievements:
11. Organization Affilliations: Within the past ten years have you been associated with any civic, cultural, educational, charitable, or work-related organizations?
Yes
No
If YES, please list all organizations including any position held in the organization and the dates of service.
12. Organization Restrictions: To your knowledge is any organization listed above restrictive on the basis of race, color, sex, national origin, disability, marital status or veteran status?
Yes
No
If YES, please describe.
13. Issues: Have you ever been publicly identified, in person or by organizational membership, with a particularly controversial national or local issue?
Yes
No
If Yes, please describe.
14. Submission of Views: Have you ever submitted oral or written views to any governmental authority, whether executive or legislative, or to the news media on any particular controversial issue other than in an official governmental capacity?
Yes
No
If Yes, please describe.
15. Associations: Have you ever had any association with any person, group, or business venture that could be used, even unfairly, to impugn or attack your character and qualifications for the position to which you are seeking appointment?
Yes
No
If YES, please describe.
16. Opposition: Do you know of any person or group who might take overt or covert steps to attack, even unfairly your appointment?
Yes
No
If so, please identify and explain the basis for the potential attack.
17. Relationship to Governmental Employees: Are you or your spouse or other close family members related to any state governmental official or employee?
Yes
No
If Yes, please provide details.
18. Compensation: During the past five years have you or your spouse or other close family members received any compensation or been involved in any financial transaction with the State of Kansas?
Yes
No
If YES, please explain.
19. Business Relationships: Have you had any business relationship, dealing, or financial transaction during the last five years, whether for yourself, on behalf of a client, or acting as an agent, which you believe may constitute an appearance of impropriety or result in a potential conflict of interest in the position to which your are seeking appointment?
Yes
No
If YES, please describe.
20. Transactions with Officials: During the past five years, have your or your spouse or other close family members received any compensation or been involved in any financial transaction with any state government official?
Yes
No
If YES, please explain.
21. Spouse or Other Family Members: Is the nature of employment for your spouse or other close family member related in any way to the position to which you are seeking appointment?
Yes
No
If YES, please indicate the employer, the position, and the length of time it has been held.
22. Lobbying Activities: During the past ten years, have you or your spouse engaged in any lobbying activities for the purpose of influencing the passage, defeat or modification of any legislative or administrative action? (Lobby activity includes any activity performed as an individual or agent of an individual, or of any organization that involve direct communication with an official in the executive branch of state government, or any official of the legislative branch.)
Yes
No
If YES, please describe.
23. Regulated Activities: Do you, your spouse, or other close family member have any interest (whether as an officer, owner, director, trustee, or partner) in any corporation, firm,
partnership, or other business enterprise and any non-profit organization or other institution that is regulated by or receives direct financial benefits from any department or agency of the State of Kansas?
Yes
No
If YES, please describe.
24. Other: Are you involved in any other matter that is or may be incompatible or in conflict with the discharge of the duties of the position to which you are seeking to be appointed or which may impair or tend to impair your independence of judgement or action in the performance of the duties of that position?
Yes
No
If YES, please describe.
25. How would you resolve any potential conflicts of interest that, while maybe unforeseen at this point in time, could arise?
26. Citations: Have you ever been cited for a breach of ethics for unprofessional conduct by, or been named in a complaint to any court, administrative agency, professional association, disciplinary committee, or other professional group?
Yes
No
If Yes, please provide details
27. Convictions: Have you ever been convicted of or entered a plea of guilty or nolo contendere or forfeited collateral for any criminal violation other than a traffic infraction? (Please include any offenses of driving under the influence, operating while impaired, reckless driving or the equivalent offenses in other states.)
Yes
No
If YES, please provide details.
28. U.S. Military Convictions: Have you ever been convicted by any military court?
Yes
No
If YES, please provide details.
29. Imprisonment: Have you ever been imprisoned, been on probation, or been on parole?
Yes
No
If YES, please provide details.
30. Agency Proceedings/Civil Litigation: Are you presently, or have you ever been, a party in interest in any administrative agency proceeding or civil litigation that is related in any way to the position to which you are seeking an appointment?
Yes
No
If YES, please provide details.
31 (a). Agency Proceedings and Civil Litigation of Affiliates and Family: a) Is your spouse or other close family member currently, or ever been, a party of interest in any administrative agency proceeding or civil litigation that is related in any way to the position to which your are seeking appointment?
Yes
No
If YES, please provide details.
31 (b). Has any business in which you, your spouse, close family member or business associate are or were an officer, director or partner been a party to any administrative agency proceeding or civil litigation relevant to the position to which you are seeking appointment? (With respect to this question, you need only consider proceedings and litigation that occurred while you, your spouse, close family member, or business associate were an officer of that business.)
Yes
No
If YES, please provide details.
32 (a). Other Litigation: Other than the litigation described in the previous 2 questions, have you or any business in which you are or were an officer, director, or partner been a plaintiff or a defendant in a civil lawsuit?
Yes
No
If YES, please describe.
32 (b). Are you aware of any pending or anticipated litigation against you or any business in which you are an officer, director or partner?
Yes
No
If YES, please describe.
33. Driver's License: Has your driver's license ever been suspended or revoked?
Yes
No
If YES, please describe.
34. Parking Tickets: Do you have outstanding parking tickets from any jurisdiction that have remained unpaid for more than 60 days?
Yes
No
If YES, please explain.
35. Security Clearance Denial: Have you ever been denied a military or other governmental clearance?
Yes
No
If YES, please explain.
36 (a), Firings: During the past ten years, have you been fired from a job for any reason?
Yes
No
If YES, please explain.
36 (b). During the past ten years, have you quit a job after being told that you would be fired?
Yes
No
If YES, please explain.
36 (c). During the past ten years, did you leave a job by mutual agreement because of specific problems?
Yes
No
If YES, please explain.
37. Alimony and Child Support: Are you now, or have you ever been delinquent in the payment of alimony or child support?
Yes
No
If YES, please explain.
38. Consumption of Alcohol: Have you ever or are you currently abusing alcohol?
Yes
No
If YES, please explain.
39. Controlled Substances: Have you ever or are you currently engaged in the illegal use of a controlled substance or abusing the use of a prescribed controlled substance?
Yes
No
If YES, please explain.
40. Appropriate Office Behavior: Have you ever knowingly accessed online pornography in the workplace?
Yes
No
41. Physical Examination: If you receive a conditional offer of appointment or employment, would you be willing to take a physical examination, which may include a drug test?
Yes
No
42. Governmental Delinquencies: Are you delinquent in the payment of any obligation owed to the federal or state government or any political or taxing subdivision or any instrumentality thereof? (Including delinquencies in the payment of: Income, property, or other taxes; exactions, fees or special assessments; loans, including any defaults, on or under loans which are or were made by, guaranteed, insured or subsidized by any unit of government or instrumentality thereof; overpayment of benefits; required payments into of under governmental programs; payments under a diversion arrangement or other repayment schedule.)
Yes
No
If YES, please explain.
43. Other: Is there any additional information, favorable or unfavorable, which you feel should be considered in connection with your appointment?
Yes
No
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.