Form No. 305 Prescribed by Secretary of State (6-11)
Questionnaire for Prospective Appointment as
Director or Deputy Director of the
_____________________ County Board of Elections
Full Name
_______________________________________
Date _______________________
(please print)
Present Home
Address
_____________________________________________ City ________________________
_______________
_______________________ ________________________________
Zip Code
Home or cell phone number
E-mail address
Date of Birth _______________
Aliases or Maiden Name ___________________________________
Driver’s License Number __________________________________ SS# ________________________
Previous addresses in past ten years
(include years of residence, city & state)
______________________________________________________________________________________________
______________________________________________________________________________________________
When answering the following questions, please attach additional sheets as necessary.
1.
Are you currently holding any elected office?
If yes, please identify.
Yes
No
_________________________________________________________________________________
2.
Are you currently holding any appointed office for which
you must subsequently be elected? If yes, please identify.
Yes
No
__________________________________________________________________________________
3.
Have you ever been convicted of a misdemeanor (other than minor traffic-related offenses) or a felony?
If yes, provide details of the conviction (what, when and where and
Yes
No
final disposition)
___________________________________________________________________________________
4.
Are there any circumstances, which might present a conflict of interest
with the administrative duties as director or deputy director of the
board of elections? (see SOS ethics policy, Directive #2007-35)
If yes, please identify.
Yes
No
____________________________________________________________________________________
5.
Please describe any employment or interests in contracts you have had with the board of elections
within the last 24 months.
____________________________________________________________________________________
6.
Have you ever been required, as a candidate or campaign treasurer,
to file a campaign finance report with any board of elections or the
Secretary of State?
Yes
No
_____________________________________________________________________________________
7.
Has a campaign in which you were involved as a candidate or
treasurer ever been the subject of a referral or complaint to the
Ohio Elections Commission? If yes, please explain.
Yes
No
_____________________________________________________________________________________
Signature ______________________________________
Date: ________________
Send to: Secretary of State’s Office, Attention: Myra Hawkins, P. O Box 2828, Columbus, OH 43216
1
