Policy Committee Application

Thank you for your interest in serving on the District's Policy Committee as the Public Member.

Please complete the application form below. Applications are due Friday, September 21, 2018 by 5 p.m.

Policy Committee Application

The information from this application will be used exclusively by the Board of County Commissioner's office, Hamilton County, Ohio. Hamilton County, Ohio is an equal opportunity employer and will not use any of the information you provide to discriminate against you on the basis of race, color, religion, sex, national origin, handicap, age, or ancestry. Please note that this form with your answers is subject to public disclosure under the Ohio Open Records Law, subject to certain redaction permitted by law. This information must be completed in full. Answer "none" or "not applicable" where appropriate. Hamilton County Boards and Commissions members are required to be electors (registered voters) of Hamilton County, Ohio. 

Are you a registered voter in Hamilton County, Ohio?  Yes    No


Residence Address (Street, City, State, Zip Code)

Residence Phone  Cell Phone 



Business/Employer Name 

Business/Employer Address (Street, City, State, Zip Code)

Business Phone 

Specify Contact:  Business  Residence  Cell

Do you currently serve on a Hamilton County appointed Board or Commission? If so, which one(s):
Are you applying for reappointment to a Board or Commission on which you currently serve? If yes, how many terms have you served on this Board or Commission?
High School or equivalent:  

Undergraduate School:  

Graduate School:  
Please explain your reason for seeking this board/commission appointment, and what you hope to bring to the board through your service:

List any relevant non­paid work experience, internship, civic or volunteer activities:

List previous addresses in the past ten years (include number of years, residence, city and state):

List employment history over the past ten years (include number of years, employer, city and state):
List any disciplinary action taken against you, for a breach of ethics or unprofessional conduct, by any employer, professional regulatory board or institution: 

Are you currently in arrears on any court­-ordered child support payments? If yes, please explain:

Have you been publicly identified with a controversial national, state, or local matter related to any issue that may be presented before the Board(s) or Commission(s) to which you are applying? If yes, please explain:

Have you ever submitted oral or written statements to any government authority or the news media on topics related to any issue that may be presented before the Board(s) or Commission(s) to which you are applying? If yes, please explain: 

Please disclose all joint holdings of real or personal property, business partnerships, or joint business or partnership interests, you or members of your family maintain with any current County public officials or member of their family, or other official associated with the board for which you are seeking appointment. Please disclose both the official(s) and nature of the relationship. 
Do you own real property, personal property, financial holdings or receive income from any source which might present a potential conflict of interest or appearance of conflict of interest with your requested appointment? If yes, please explain: 
Within the past three years, have you been assessed a penalty for failure to file a timely federal, state or local personal income tax return or for failure to pay taxes owed? If yes, please explain: 
Within the past three years, has any business venture for which you were a person responsible for remitting withholding taxes or sales taxes, failed to pay such taxes in a timely manner? If yes, please explain:
Please disclose all County elected officials to whom you have made campaign contributions over the last four years. Note: this information has already been publicly disclosed in finance reports.  It is not disqualifying, but simply aids in transparency.

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