Application For Appointment To The Board Of Review (Page 2 of 12) in pdf

Application For Appointment To The Board Of Review Page 2

II.

Personal Information

Full Name: (First, Middle, Last):

First Name

M.I.

Last Name

Residential Address: (Street, Town, State, Zip Code):

Street

Town

State

Zip Code

Contact Telephone Number:

Contact Fax Number:

Contact Email Address:

10.

Social Security Number:

11. Per Executive Order 444, please disclose any immediate family members, including those related to your

immediate family by marriage, who are employed by the Commonwealth of Massachusetts. You are required to

complete the information below. “Immediate family” is defined as a spouse, child, parent and sibling. Include

those employed in all branches of state government: judicial, legislative, executive, higher education and state

authorities; and those employed as regular or contract employees or elected officials. This “sunshine disclosure”

is intended to ensure that the citizens of the Commonwealth have full confidence in their government and its

hiring process. The disclosure will not be used to exclude any qualified applicant seeking a position within the

Executive Branch from receiving full consideration based on the merits of his/her credentials and the

requirements of the job.

Name of Relative

Title of Job

State Agency

III.

Education

Application For Appointment To The Board Of Review Page 2