Application for Appointment to Macon County Authorities, Boards, Commissions and Committees

Application for Appointment to Macon County Authorities, Boards, Commissions and Committees

The Macon County Board of Commissioners (Board) believes all citizens should have the opportunity to participate in governmental decisions. The Board wants to appoint qualified, knowledgeable, and dedicated people to serve on authorities, boards, commissions, and committees. If you are interested in being considered for an appointment to any advertised vacancy, please thoroughly complete the form below before the advertised deadline and choose from the following options.
If you have any questions, please contact the Office of the Deputy Clerk to the Board at 828-349-2020
Name of Authority, Board, Commission, or Committee for which you are applying to serve on*
Contact Information
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Preferred Name*
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Number*
Education
High School Name*
Graduated
Year Graduated
College Name
Year Graduated
Graduated
Degree
Post Grad College Name
Graduated
Year Graduated
Degree
Employment Status
Please provide your current employment status*

Full-TimePart-TimeSelf EmployedRetiredUn-Employed
Employer
Job Title
Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Person
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employment Date

MonthDayYear
Date
Professional Licenses held (if applicable)
Previous employment or experience
Membership in professional, civic organization or government boards or commissions
Community Service/Volunteer Activities
Could you or your family be affected financially by decisions made by the board or commission for which you are applying?

YesNo
If yes please explain
Why do you want to serve on this Authority, Board, Commission, or Committee ?
Please list any special skills, interest or qualifications which you feel would be an asset to said board or commission
How did you learn of the opening on the Authority, Board, Commission, or Committee for which you are applying?
Are you registered to vote in the state of North Carolina

YesNo
Are you a full time resident of Macon County

YesNo
Are you a Macon County property owner

YesNo
If you are applying for the Nursing Home Adult Care Advisory Committee
Do you or someone in your immediate family have a Financial interest in a nursing home located in Macon County?

YesNo
Is someone in your immediate family a resident in a nursing home located in Macon County?

YesNo
References
First Reference

First NameLast Name
Title
Organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship
Second Reference

First NameLast Name
Title
Organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship
Third Reference

First NameLast Name
Title
Organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship
Conflict of Interest Disclosure
Full Name of Spouse (if married)

PrefixFirst NameMiddle NameLast NameSuffix
Spouse's Place of Employment
Spouse's Position/Title
Please list all entities of which you or your spouse are an officer, director, trustee, partner or employee, or have at least a five percent (5%) ownership interest, and describe your affiliation with such entity (if there are none, please state "none"

By submitting this Application for Appointment, I pledge that, if appointed, I agree by my signature below that all of the information above is complete and accurate to the best of my knowledge and I pledge to comply with the following ethics guidelines as fully set forth in the Code of Ethics.

I. Declaration of Policy

The proper operation of democratic government requires that public officials and employees be independent, impartial and responsible to the people; that governmental decisions and policy be made in proper channels of the governmental structure; that public office not be used for personal gain; and that the public have confidence in the integrity of its government.

In recognition of these goals, a Code of Ethics for county officials was adopted. The purpose of this policy is to establish guidelines for ethical standards of conduct for all officials and to set forth actions that are compatible with the best interests of the County.

II. Applicability of Ethics Policy

The provisions of this policy shall apply to all elected and appointed county officials, members of County Boards and Committees appointed by the County Commissioners and other County employees.

III. Financial and Personal Disclosure

Any County official or employee who must officially consider any public matter involving his financial or personal interests or those of his immediate family, shall first publicly disclose the nature and extent of such interest and shall abstain from acting thereon unless provisions of state law require otherwise.

IV. Gifts and Favors

No official or employee shall knowingly accept any gift, whether in the form of money, thing, favor, loan or promise, when it could reasonably be inferred that the gift was intended to influence or reward an official action on his part. Gifts, meals, other favors of an incidental nature and of minor value (less than $100), or legitimate political contributions shall not be included in this policy.

V. Appointment, Employment, or Contract Award of Relatives or Business Partners

Public officials of the appointing authority must disclose on the public record any person of their immediate family related by blood or marriage or business interest who is being considered for appointment, employment, or contract award by that authority.
I would like to be considered for appointment to serve, without compensation, on a county Authority, Board, Commission, or Committee and I hereby certify by signing that all of my Macon County property taxes are paid in full. I realize that, because I have volunteered, it in no way guarantees that I will be appointed to a Authority, Board, Commission, or Committee by the Macon County Board of Commissioners.
Upon appointment to a Board/Committe, the information contained herein becomes a matter of public record per North Carolina Statute 132-1
Signature*

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Application for Appointment to Macon County Authorities, Boards, Commissions and Committees

If you have any questions, please contact the Office of the Deputy Clerk to the Board at 828-349-2020

Contact Information

Education

Employment Status

If you are applying for the Nursing Home Adult Care Advisory Committee

References

Conflict of Interest Disclosure