Gaming advisory board chair Justin Warren resigned his position after being elected as chair of the Dauphin county republican party.
Jeff Haste explained that the open seat for the fifth board member was restricted to a residents of the seven contiguous municipalities of Hollywood Casino.
This is the application form listed on the county web site for all advisory/authority/commission boards.
______________________________
Personal Information
Dauphin County
APPLICATION FOR APPOINTMENT
Return to: Dauphin County Board of Commissioners P.O. Box 1295 Harrisburg, PA 17108-1295 717.780-6300
Full Name:___________________
Age:___________
Address:_______________________
Township/Municipality:______________
Resident of Dauphin Co. since:_________
Daytime Telephone#:________________
Evening Telephone#___________________
I request appointment to the following Board/Authority/Commission: _______________________________
- Employment Information Current Employer:______________
Job Title:______________________
Employer Address:________________________
Telephone#:__________________________
Hours of Employment:_____________________
Fax#:________________________________
- Educational Background High School:__________________________
Graduate? Yes___ No___
College:_____________________________
Graduate? Yes___ No___
Application for Appointment; Page #2
- Educational Background, Cont’d.
Other:_____________________________
Graduate? Yes___ No___
- Please answer all of the following questions. If additional space is required, use the back side of this form.
1. If appointed, how much time can you devote to the municipal body?______________________________
2. On what date would you first be available for service?_______________________________
3. Are you or have you ever been a member or supported any organization, association, group or movement that advocates the violent of or forceful overthrow of the Government of the United States or the Commonwealth of Pennsylvania or any municipal governmental bodies within the Commonwealth in violation of the Constitution of the United States or the Commonwealth or which organization, association, group or movement promotes or advocates the denial of any person’s civil rights by unconstitutional means?
No:_____
Yes (Please state particulars):___
_____________________
4. Are you delinquent in the payment of Dauphin County, Municipality, or School District Real Estate Taxes? No:____
Yes (Please state particulars)____
5. Do you own any property in Dauphin County or have any controlling interest in a partnership, corporation or other entity which owns property; where that property is presently subject to a tax lien for unpaid taxes?
No:____
Yes: (Please state particulars)____
6. Are you a member of any organization where your membership may constitute an actual conflict of interest with Dauphin County or may give the appearance of a conflict of interest?
No:____
Yes (Please state particulars):____
7. Have you ever been convicted of a felony or misdemeanor of the first or second degree?
No:____
Yes (Please state particulars):____
8. Have you ever been subject to a finding of child abuse?
Yes:____ No:____
Application for Appointment; Page #3
9. Have you ever been subject to a finding of sexual harassment? Yes:____ No____
10. Have you ever filed a petition in bankruptcy? Yes:____ No:___
_ 11. Dauphin County adheres to the tenets of the Drug Free Workplace Act and has zero tolerance for the use of unlawful drugs in the workplace. Are you willing to support the provisions of this Act?
Yes:____ No:___
_ 12. Are you an active member of any nonprofit, civic, charitable or community-based organizations?
No:____ Yes
(List organizations):____
___ 13. Are you a registered voter? Yes:____ No:____
14. The Board of Commissioners desires to appoint individuals who will be active participants on County boards and commissions, including regular attendance of scheduled meetings. Are you willing to be an active board member and attend scheduled meetings?
Y es:____ No:____
15. What special skills do you possess (inlcuding hobbies and leisure activities) that may enhance your service?
________________________
- Information required for background check Full Name:______________________
Former Name(s); if any?_____________________
Social Security Number:_____________________
Date of Birth:___________________
The information above is used solely for the purpose of the background check.
Application for Appointment; Page #4
- Please state your reasons for requesting appointment to the above municipal body(ies) and attach a brief professional resume.
(Print or type)___________________
In signing, I do solemnly swear (or affirm) that this application contains no misrepresentation, falsification or omission and that the information given by me and complete to the best of my knowledge and belief.
Furthermore, I do solemnly swear (or affirm) that I will support, obey and defend the Constitution of the United States and the Constitution of the Commonwealth of Pennsylvania, and that I will discharge the duties of my office with fidelity.
I consent to an investigation of my background and any information provided herein, including a criminal history check.
Signature __________________ Date
Updated to include the application form.