Form 302-B - Questionnaire For Prospective Appointment As A Member
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1Form No. 302-B Prescribed by Secretary of State (12-15)
Questionnaire for Prospective Appointment as a Member
of the _____________________ County Board of Elections
Please return YOUR RESUME with your completed form.
Full Name
_______________________________________
Date _______________________
(please print)
Present Home
Address
_____________________________________________ City ________________________
_______________
_______________________ ________________________________
Zip Code
Home telephone 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)
______________________________________________________________________________________________
______________________________________________________________________________________________
Business
Address
____________________________________________ City _________________________
______________
_________________________
____________________________
Zip Code
Occupation
Business telephone number
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 of a member of the board
of elections? (see enclosed ethics policy)
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
Please list all campaigns, political parties, political action committees; etc. for
which a campaign finance report was filed by you as a candidate or as treasurer.
_____________________________________________________________________________________
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
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