Application For Appointment To The Board Of Review (Page 11 of 12) in pdf

Application For Appointment To The Board Of Review Page 11

36.

CERTIFICATION AND WAIVER

I hereby swear or affirm under penalties of perjury that the information provided within my

application is true and complete to the best of my knowledge and belief; and that I am a citizen of the

United States and of the Commonwealth of Massachusetts.

I waive any privilege of confidentiality I may have with respect to information concerning my

qualifications for appointment to the Board of Review that the DUA State Advisory Council and/or the

screening subcommittee may desire to obtain. I specifically authorize the DUA State Advisory Council

and the screening subcommittee to obtain and examine my personnel files from current and past

employers, including all files maintained by the Massachusetts Court System, and to obtain information,

records and documents regarding me from any credit reporting agency, any law enforcement agency, any

bar association, any occupational licensing board, any educational institution, and any disciplinary body,

including specifically the Board of Bar Overseers. I further authorize these institutions, organizations, and

individuals, and any other institutions, organizations and individuals to make available to the Panel all

confidential and non-confidential documents, records and information concerning me that the Panel may

request.

I understand the submission of this application expresses my willingness to accept appointment to

the Commonwealth of Massachusetts, Division of Unemployment Assistance, Board of Review, if

tendered by the Governor. Further, I swear or affirm that I have received and reviewed a copy of the

Board of Review Nomination process and will abide by that process – including the provisions contained

in Section 2.1 regarding “Code of Conduct”.

Signature of Applicant

Printed Name of Applicant

Date

Application For Appointment To The Board Of Review Page 11