Nomination application

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Nominate yourself for an appointment to one of the Boards or Commissions listed below.

The information we collect will be used by the President’s office in considering you for an appointment. It will be kept confidential and protected from disclosure to the extent permitted by law.

If you have a problem completing the form, please email:
CookCounty.Appointments@cookcountyil.gov.

*NOTE: All fields are required for this application to be considered complete. Please provide accurate information in ALL applicable fields.

BOARD OR COMMISSION SOUGHT

Select the Board or Commission for which you would like to be considered:

I am applying for a reappointment.

I would like to be considered for other appointments for which I am qualified.

PERSONAL INFORMATION

Honorific

First Name

Middle Name

Last Name

Social Security Number

Address

Address line 2

City

State | Postal Code
|

Township

Country

Home Phone

Alternate Phone

RESIDENCY

Are you a resident of Cook County?
Yes No

If so, since what year have you been a continuous resident?

Over the past twelve months, estimate the percentage of time you resided outside of Cook County.
%

Are you a United States Citizen?
Yes No

If you are not a US Citizen, are you eligible to work in the United States?
Yes No N/A

Please list all of your former or current residences (both in and outside of Illinois) that you have maintained at any time since age 18 or within the past 10 years, whichever may be shorter (at a minimum, please indicate the city and state in which you resided and the period of time at that location):

Are you a registered Illinois voter?
Yes No

If yes, indicate county of registration:

If no, indicate state of registration:

When was the last year you voted?

EDUCATION

High School

High School name:

High School location:

Post-Secondary

List the last four post-secondary educational institutions attended. List the most recent school first:

	Institution	Location	Dates Attended	Certificates/Degrees Received
1
2
3
4

At any time during your post-secondary education, were you subject to any disciplinary action, suspension or expulsion?
Yes No

If yes, please explain.

MILITARY HISTORY

Veteran Status
Veteran Not a Veteran

If Veteran, Branch of Military Service:
N/A Air Force Air National Guard Army Army National Guard Coast Guard Marine Corps Navy

(If applicable) At any point during your service in the armed forces, were you subject to disciplinary action?
Yes No

If yes, please explain.

EMPLOYMENT AND PROFESSIONAL HISTORY

Provide employment history, listing the most current first:

Employer	Title	City/State	Start Date	End Date

Please list all corporations, partnerships, trusts or other business entities with which you have ever been affiliated as an officer, director, trustee or partner, or holder of a significant equity or financial interest (i.e., any ownership interest of more than five percent), or whose decisions you had the ability to significantly influence:

Please chronologically list activities, other than your work experience, from which you have earned income in excess of $2,500 in any calendar year (e.g., self-employment, consulting activities, writing, speaking, royalties and honoria) during the past ten years:

Have you ever been formally disciplined by an employer (e.g., fired, suspended, reprimanded)?
Yes No
If yes, please explain.

Have you ever submitted a false resume or job application?
Yes No
If yes, please explain.

ORGANIZATIONS AND CIVIC AFFILIATIONS

List all organizations and societies of which you are currently a member.

Are you or your spouse/domestic partner, or have you or your spouse/domestic partner ever been, a member of any club or membership organization that, in practice or policy, restricts membership on the basis of age, race, religion, national origin, sexual orientation, gender or disabled status?
Yes No
If yes, please explain.

GOVERNMENT AFFILIATION AND EXPERIENCE

For purposes of this section, the terms “RELATED TO” and “IMMEDIATE FAMILY” shall mean those people related to the individual as father, mother, son, daughter, brother, sister, uncle, aunt, great aunt, great uncle, first cousin, nephew, niece, husband, wife, grandfather, grandmother, grandson, granddaughter, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, half-sister, and including the father, mother, grandfather, or grandmother of the individual’s spouse and the individual’s fiancé or fiancée.

Are you now or were you ever a public official?
Yes No
If yes, what office do/did you hold?:

Is your spouse/domestic partner now or were they ever a public official?
Yes No N/A
If yes, what office does/did your spouse/domestic partner hold?:

Are you or your spouse/domestic partner related to any public officials or employees?
Yes No
If yes, please provide name(s), relationship(s) and position(s) held.

Have you ever been a registered lobbyist or lobbied any level of government during the past five years?
Yes No
If yes, please indicate whether you received any compensation for lobbying activities, and list the group(s) you represented.

Has your spouse/domestic partner ever been a registered lobbyist or lobbied any level of government during the past five years?
Yes No
If yes, please indicate whether your spouse/domestic partner received any compensation for lobbying activities, and list the group(s) he/she represented.

Have you ever run for political office or served on a political committee?
Yes No
If yes, please explain.

If you have ever run for political office, does your campaign or political committee have any outstanding campaign debt?
Yes No N/A
If yes, are you personally liable for that debt?
Yes No

Please attach a list of individuals, corporations and other organizations who contributed more than $1,000 to your campaign or political committee in the aggregate during any one election.
Browse to select the document and upload below:
Files must be less than 5 MB and in PDF, DOC(X), RTF or TXT format

Are you or your spouse/domestic partner, or have you or your spouse/domestic partner ever been, employed by Cook County government or any federal, foreign, Illinois or other state, or local government entity or agency?
Yes No
If yes, please identify the position(s), the name(s) of the employing entity, and the period(s) of employment.

Have you ever been appointed to a state or local government board or commission?
Yes No
If yes, please identify the position(s) and the period(s) of your service.

Have you ever been publicly accused of failing to act in an ethical manner in connection with public employment or public service?
Yes No
If yes, please explain.

CONFLICTS OF INTEREST

For purposes of this section, the terms “RELATED TO” and “IMMEDIATE FAMILY” shall have the same meaning as section GOVERNMENT AFFILIATION AND EXPERIENCE above.

Have you or any member of your immediate family (or any company in which you or any member of your immediate family holds an ownership interest in excess of five percent or serves as an officer or principal) held a contract with a federal, state or local government entity at any time during the last five years?
Yes No
If yes, please explain.

Have you or any member of your immediate family been affiliated with any corporations, institutions or other entities within the past five years which might present a conflict or appearance of a conflict with the position you are seeking?
Yes No
If yes, please explain.

Do you or any member of your immediate family own real property, personal property or financial holdings or receive income from any source which might present a potential conflict or appearance of a conflict with the position you are seeking?
Yes No
If yes, please explain.

Do you currently serve on any private or non-profit board or commission?
Yes No
If yes, please describe the board or commission and your role.

LEGAL AND FINANCIAL MATTERS/ADDITIONAL BACKGROUND INFORMATION

For purposes of this section, the terms “RELATED TO” and “IMMEDIATE FAMILY” shall have the same meaning as section GOVERNMENT AFFILIATION AND EXPERIENCE above.

Have you or any member of your immediate family ever been convicted of any crime or violation (including traffic violations for which a fine of $100.00 or more was imposed, and any conviction for driving under the influence of alcohol and/or drugs)?
Yes No
If yes, please briefly describe the nature of the offense, date of conviction and sentence received.

Are you or any member of your immediate family currently under federal, state or local investigation for possible violation of a criminal law?
Yes No
If yes, please explain.

Has any law enforcement agency of any kind (police, State’s Attorney, FBI, IRS, U.S. Attorney, etc.) ever requested an interview of you for any purpose or reason?
Yes No
If yes, please explain.

Have you ever been called to testify before or provide documents to a grand jury?
Yes No
If yes, please explain.

Have you ever been the subject of a professional disciplinary proceeding or had any professional license or permit revoked?
Yes No
If yes, please explain.

Have you ever been delinquent in paying, or failed to pay, any child support or alimony payment?
Yes No
If yes, please explain.

Have you ever had your driver’s license suspended?
Yes No
If yes, please explain.

Has any regulatory agency ever filed a complaint against you or any company in which you have an ownership interest in excess of five percent or of which you have been an officer or principal?
Yes No
If yes, please explain.

Have you or any member of your immediate family ever been involved in a civil litigation proceeding?
Yes No
If yes, please explain.

Have you ever been refused or granted a fidelity, surety or other bond?
Yes No
If refused, please explain.

Have you or your spouse/domestic partner failed to file income tax returns for any of the past five years?
Yes No
If yes, please explain.

Have you or your spouse/domestic partner ever filed a late tax return without a valid extension, paid any tax penalties, or had a tax lien or other collection procedure instituted against you?
Yes No
If yes, please explain.

Have you, your spouse/domestic partner, or any company in which you have an ownership interest in excess of five percent or of which you have been an officer or principal been involved in any bankruptcy proceeding?
Yes No
If yes, please explain.

Have you ever defaulted on a personal, business or student loan?
Yes No
If yes, please explain.

Since the age of 18 or in the last 15 years, whichever is shorter, have you illegally purchased, manufactured, transported, produced, offered for sale or personally used any controlled substance or contraband item?
Yes No
If yes, please explain.

Have you ever submitted oral or written views to any government authority, media outlet, or public forum (including internet websites) on any controversial issue other than in an official government capacity?
Yes No
If yes, please explain.

Have you ever been identified publicly with a controversial national, state or local issue which should be considered in the context of your appointment?
Yes No
If yes, please explain.

Have you ever had any association with any person or group or business venture which could be used, even unfairly, to impugn or question your character, judgment and/or qualifications for the requested appointment?
Yes No
If yes, please explain.

Do you know anyone who might take steps, overtly or covertly, to oppose your appointment?
Yes No
If yes, please explain.

Is there anything in your background which, if made public, could cause embarrassment to President Preckwinkle or her Administration?
Yes No
If yes, please explain.

Please list each book, article, column or publication you have authored, individually or with others.

Please list any professional certifications you hold.

Please list and describe any professional awards or merits you have received.

Please list all loans for yourself and your spouse/domestic partner that are currently outstanding and identify the creditors for each loan. You may exclude credit card debt and any other loan (i) made by a lender whose primary business is making the loans, and (ii) having an interest rate, loan term, and other conditions reflecting market rates and conditions at the date of the loan.

INTEREST AND QUALIFICATIONS

Please briefly explain why you wish to serve on a County board or commission.

What unique characteristics, qualifications and experiences would you bring to a County board or commission?

What additional information would you like us to know to better assess your suitability for a position on a County board or commission?

DEMOGRAPHIC INFORMATION

Gender
Male Female

Ethnicity
African American Asian American Latino Native American White Other No Response

Date of Birth

RESUME AND REFERENCES

Resume Upload: Browse to select your resume file and upload below:
Files must be less than 5 MB and in PDF, DOC(X), RTF or TXT format

Work References: List three work references who will be available to discuss your qualifications. Include their names, telephone numbers, mailing addresses and e-mail addresses.

Name	Telephone Number	Mailing Address	City/State/Zip	E-mail Address

Personal References : List three personal references who will be available to discuss your qualifications. The references must be persons you have known for at least five years, and cannot be related to you. Include their names, telephone numbers, mailing addresses and e-mail addresses.

Name	Telephone Number	Mailing Address	City/State/Zip	E-mail Address

CERTIFICATION AND SUBMIT

By checking this box and clicking the submit button below, I hereby certify, to the best of my knowledge, that the foregoing responses and any attached documents and statements are true, accurate and complete. I understand and agree that any material misstatement, misrepresentation, or omission may result in my immediate disqualification for appointment. I authorize Cook County to review my credit and criminal history, and/or to request more information about my background.

Please provide the following to submit your application and receive a reply confirmation via email:

Your Email

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