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Ashtabula County, OH

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Board Application

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Steps

1. Step One This section is complete This section is incomplete
2. Step Two This section is complete This section is incomplete
3. Employment Information This section is complete This section is incomplete
4. Education This section is complete This section is incomplete
5. Board Questions This section is complete This section is incomplete
6. Signature & Date This section is complete This section is incomplete

Step One

Ashtabula County Commissioners

25 W. Jefferson St.
Jefferson, OH 44047
Ph: 440-576-3750
Fx: 440-576-2344
commissioners@ashtabulacounty.us
Please return application and/or resume to:
Ashtabula County Commissioners Attn: Lisa Hawkins, Clerk
25 W. Jefferson St.
Jefferson, OH 44047
llhawkins@ashtabulacounty.us
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Step Two

Board Applying For*
First Name*
Last Name*
Residence Address: *
City*
State*
Zip
Mailing Address (if different than residence):
Email Address
Home Phone Number
Cell Phone Number
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Employment Information

Name/Address of Current Employer
Occupation:
If retired, please give former occupation noting you are retired.
Have you notified your current employer of your interest in being on this board?
1. Yes
1. No
Will board meeting dates/times interfere with your employment or other activities?
1. Yes
1. No
Do you currently serve on an Ashtabula County appointed Board or Commission?
1. Yes
1. No
If so, which one(s):
Are you applying for reappointment to a Board or Commission on which you currently serve?
1. Yes
1. No
If yes, how many terms have you served on this Board or Commission?
Terms
Please indicate what your contributions have been to the board/commission during the time of your service and your meeting attendance history below:
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Education

Highest level of education completed
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Board Questions

Please explain your reason for seeking this board/commission appointment, and what you hope to bring to the board through your service:
Please describe any relevant past employment, education, community service or volunteer activities that would assist you on this board:
List any disciplinary action taken against you, for a breach of ethics or unprofessional conduct, by any employer, professional regulatory board or institution:
Have you ever been convicted of a violation of any law, other than minor traffic offense?
1. Yes
1. No
If so, please provide details:
Are you currently in arrears on any court-ordered child support payments?
1. Yes
1. No
If yes, please explain:
Have you been publicly identified with a controversial national, state, or local matter to any issue that may be presented before the Board(s) or Commission(s) to which you are applying?
1. Yes
1. No
If yes, please explain:
Are you aware of any circumstances that exist or could exist that would create a conflict of interest or the appearance of a conflict of interest if you are appointed to this board?
1. Yes
1. No
If yes, please explain:
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?
1. Yes
1. No
If yes, please explain:
Within the past three years, have you or any business venture you control, 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, including real estate property tax within Ashtabula County?
1. Yes
1. No
If yes, please explain:
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Signature & Date

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS STATEMENT:
I certify that all of the answers and statements made in this application are true, complete and correct to the best of my knowledge and belief and are made in good faith. I understand that any false statements will void this application and any action based upon it.
Signature*
Today's Date

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1. Receive an email copy of this form.
Email address

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Contact Us

25 W. Jefferson St.
Jefferson, OH 44047

Phone: 440-576-9090

Monday - Friday | 8 a.m. - 4:30 p.m.
Individual Office hours may vary.

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