Department of Health and Mental Hygine

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This is a two part application process, please complete BOTH the Biographical Information form and the Ethics Exemption Disclosure form. Failure to complete either one of these forms will prevent us from accepting your application for Appointment consideration. Please state here, the board or commission or general subject area in which you have an interest:


Appointment :

     Board or Commission Name* :  
     First Name: *         Middle Name: 
     Last Name: *    
     Maiden Name:*        
     Date of Birth:*      (mm/dd/yyyy)      
    US Citizen  Registered Voter
     MD Resident Since:*    (yyyy) 
     Race:*       Gender:*     
     (Ethnic/gender data is solely to assure diversity in representation)
    Home Address:*       City:*    
    State:*       Zip: *  
    Resident County: *  
      
    MD Legislative District #1 :*    
    MD Congressional District #2 : *  
   Council or Commission District #3 :
   Occupation:  
   Employer:  
   Work Address:
   City:  
   State:    Zip :
   Day time contact number:
   Office Phone:   Home Phone:
   Cell Phone:      Fax:
   Email Address:
   Sponsoring Organization(If any):
   Have you ever been a party (plaintiff or petitioner/defendant or respondent) to any civil, criminal, juvenile or administrative proceeding?
   Visit casesearch.courts.md.us to search (Specify):
   Do you hold a Maryland license to practice a profession or trade?       If Yes, specify type of license and license number:
   Have you ever had a license to practice a profession or trade, whether held in Maryland or another state, revoked or suspended?
   Specify):
   Are you a member, officer or director of any organization?
  
   If Yes, Specify Organization or Activity:
   If so, are you engaged in any lobbying activities for that organization?
  
  Are you a paid lobbyist for any organization?   (Specify):
  Do you hold, or have you held in the past, an elected or appointed office within Federal, State or local government, or a political party?
  (Specify Office):
   Specify Date: (mm/dd/yyyy)
  Have you filed all Federal and State tax returns that are now due or overdue and are all payments thereupon up to date?
  (Explain):
  Have Federal, State or local authorities ever instituted a lien or other collection procedures against you?
   (Explain):
  List the names, business addresses, and business telephone numbers
  of at least 2 individuals who are familiar with your professional
  qualifications and who have known you for more than the last five years:
   
 
   ORGANIZATIONAL AFFILIATIONS:
  
  In less than 200 words, please feel free to include a brief message to the
  Secretary of Appointments or the Staff regarding your application.
 

                                        
  When clicking "NEXT" you will be directed to the second part of the
  Appointment application process. The information requested on the
  following form complies with Section 502 of the Maryland Ethics Law (Md.
  Code Ann., State Gov't Article, Title 14). Please follow the instructions.