This is a form for application for Apointment to a Board of Regents of a Ky. College or University, you should send this in with a resume.

COMMONWEALTH OF KENTUCKY

INFORMATION FOR UNIVERSITY BOARDS AND POSTSECONDARY EDUCATION COUNCIL

Return Completed Form To:

Regina Crawford, Executive Director for Boards

and Commissions

Room 100, State Capitol

Frankfort, KY 40601

(FAX 502-564-0437)

  Your Name (Last, First, Middle)                                                                      County                                   Supreme Court District                       

 Mr.                                                                                                                                                                        

 Ms.

 Mrs.

 Home Address                                                    City                                         State                                       Zip

 Date of Birth                                                                                                        *Party Affiliation:  Dem. Rep. Ind.                    Race

                                                                                                                                (Underline one)

 Your Occupation                                                 Business Phone Number & Fax Number                          Residence Phone Number

 Email address                                                                                                                 Mobile Number

 Current Employer                                                Business Address

 Spouse’s Name                                                   Spouse’s Employer

EDUCATION AND GENERAL QUALIFICATIONS:

 Level                                                     Name of School                                    No. Years               Did you                  Major Course(s) of

                                                                                                                                Attended               Graduate                Study

 High School

 College/Other     

Memberships in Organizations.

Also Indicate Current Positions

With Political Party or

Organization.

Indicate Any Public Office

Currently Held.

HAVE YOU EVER BEEN CONVICTED OF A FELONY? ____ IF YES, PLEASE INDICATE CHARGE, DATE AND PLACE.

REFERENCES (List two persons not related to you, whom you have known for at least one year)

 Name                                                     Address                                                 Phone Number                                      Years Acquainted

·         Necessary in order to comply with state law in regard to balance

CURRENT RESUME MAY ALSO BE SENT

DATE: _________________________________________   SIGNATURE: _____________________________________
                                  COMMONWEALTH OF KENTUCKY

UNIVERSITY BOARDS AND COUNCIL ON POSTSECONDARY EDUCATION

                          CONFLICT OF INTEREST QUESTIONNAIRE

NAME (Please Print) ________________________________________________________________________________________

1.  Are you employed by a public institution of higher education in Kentucky? _____________.  If yes, with which institution and in what capacity? ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

2.  Do you have a relative* employed by a public institution of higher education in Kentucky? ___________________ If yes, provide the name and the address of the relative and the institution with which he or she is employed and the position held. ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

*Relative: father, mother, brother, sister, husband, wife, son, daughter, uncle, aunt, son-in-law, or daughter-in-law.

3.  Are you an officer or director of any corporation which does business with a public institution of higher education in Kentucky? _________________.  If yes, please list the names of the corporation, the office held, and the approximate dollar amount of business involved.__________________________________________________________________________________

__________________________________________________________________________________________________________

4.  Do you, or does any relative of yours, have a financial interest in, or receive any remuneration or income from, any business organization which has business dealings with a public institution of higher education in Kentucky?___________ If yes, please supply the following information:

A.  Names of the business organizations in which such interest is held and the person(s) by whom such interest is  held_______________________________________________________________________________________________

 __________________________________________________________________________________________________

B.  Nature and amount of each such financial interest, remuneration or income;                                                                            __________________________________________________________________________________________________

__________________________________________________________________________________________________

5.  Did you, or any relative of yours receive, during the past twelve months, any gifts or loans from any source from which a public institution of higher education in Kentucky buys goods or services or has significant business dealings? _________.

If yes, list such gifts or loans as follows:

NAME OF SOURCE                                                           ITEM                                                      APPROXIMATE VALUE

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Date: _____________       Signature: ______________________________________________

                                                                     * * * * * * * * * * * * * * * * * * * * * * * * *

                             PLEASE EXPLAIN ON SEPARATE SHEET WHY YOU WOULD BE WILLING TO SERVE

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