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.