Application/Nomination Form
Name of Board(s) or Agency(s) you are interested in appointment to:
Administrative Adjudication Officer
Agricultural Conservation Easement and Farmland Protection Commission
Big Rock Drainage District #2
Board of Health Advisory Committee
Chicago Metropolitan Agency for Planning (CMAP) Board
Chicago Metropolitan Agency for Planning Policy Committee
County Extension Board
Delinquent Tax Sale Agent
Drinking and Driving Task Force
Ethics Advisor
Fire Protection Districts
Aurora Township Fire Protection District
Batavia Township & Countryside Fire Protection District
Burlington Community Fire Protection District
Maple Park & Countryside Fire Protection District
Marywood Fire Protection District
Montgomery & Countryside Fire Protection District
Pingree Grove & Countryside Fire Protection District
South Elgin & Countryside Fire Protection District
Grand Prairie Sanitary District
Historic Preservation Commission
Judicial and Public Safety Technology and Strategic Planning Commission
Kane County Board of Review
Kane County Community Development Commission (CDBG)
Kane County Emergency Communications Board (KaneComm)
Kane County Emergency Telephone Systems Board (Kane ETSB)
Kane County Farmland Assessment Review Committee
Kane County Liquor Control Commission
Kane County Road Impact Fee Advisory Committee
Kane County Stormwater Management Planning Committee
Kane-Elgin HOME Commission
Lake Marian River Conservancy District
Longmeadow Parkway Corridor Task Force
Mental Health Advisory Committee
Metra Board of Directors
Mill Creek Special Service Area Advisory Body
Mill Creek Water Reclamation District
Northwest Kane Airport Authority
Pace Board of Directors
Plato Rutland Drainage District
Public Building Commission
Regional Planning Commission
Regional Transportation Authority (RTA) Board of Directors
Rob Roy Drainage District #2
Sheriff’s Merit Commission
Sugar Grove Drainage District #1
Upper Illinois River Valley Development Authority (UIRVDA)
Zoning Board of Appeals
Have you ever served on this Board or Agency before?
Yes
No
If so, how long?
Personal Information
Last Name:
First Name:
Middle Initial:
Date of Birth:
E-mail Address:
Present Permanent Address:
City:
Zip Code:
County:
Home Phone:
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Alternate Phone:
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Educational Information
High School
Name and Address of High School Attended:
Date of Graduation:
College/University
College/University Name and Location of School
Degree Earned
Date of Graduation
College/University Name and Location of School
Degree Earned
Date of Graduation
Employment & Professional History
Please list current & previous employers.
Employer’s Name:
Mailing Address:
Telephone No.:
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Position Held:
Start:
End:
Employer’s Name:
Mailing Address:
Telephone No.:
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Position Held:
Start:
End:
Employer’s Name:
Mailing Address:
Telephone No.:
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Position Held:
Start:
End:
Please list any professional certifications you hold:
Additional Information
Please explain why you wish to serve as an appointee and share any unique qualifications or experience you feel you would bring to this agency.
Are you a lobbyist registered with the State of Illinois?
Yes
No
Are you (or your spouse) an elected official?
Yes
No
If yes, please describe:
Are you (or your spouse) a government employee?
Yes
No
If yes, please describe:
Volunteer Board & Community Participation History
Please summarize any community involvement and list any government, non-profit or private sector boards on which you currently or previously served as a board member or volunteer.
Organization Name:
Start:
End:
Activities:
Organization Name:
Start:
End:
Activities:
Organization Name:
Start:
End:
Activities:
Conviction Information
Have you ever been convicted of a criminal offense?:
Yes
No
If so, date and location:
Nature of Conviction:
Disposition:
By checking this box and submitting this application, I hereby certify that the foregoing responses are true, accurate and complete. I agree that any misstatement, misrepresentation, or omission of fact may result in my immediate disqualification for appointment. I authorize Kane County to review my criminal history, and/or to request more information about my background.
“As a condition of the appointment I will have, at the time of my appointment, or as soon thereafter as possible, filed with the County Clerk a Statement of Economic Interest in accordance with the Illinois Governmental Ethics Act.”