Free GOVERNOR' S WORKING PAPERS - Virginia

Vetting form
GOVERNOR' S CONFIDENTIAL WORKING PAPERS

Commonwealth of Virginia

NAME: ___________________ COMMONWEALTH of VIRGINIA
P.O. Box 2454 Richmond, Virginia 23218 Telephone: (804) 786-2441; Fax: (804) 371-0017

Office of the Governor

Timothy M. Kaine Governor of Virginia

Katherine K. Hanley Secretary of the Commonwealth

Gubernatorial Appointment Vetting Form
For the following questions, all "yes" answers require detailed responses. Use a separate sheet if necessary.
1. ISSUES: In the last five years, have you been publicly identified, in person or by organizational membership, with a particularly controversial national, state, or local issue? If yes, please describe. YES ___________ NO ___________ 2. SUBMISSION OF VIEWS: In the last five years, have you submitted oral or written views to any governmental authority, whether executive or legislative, or to the news media on any particularly controversial issue other than in an official governmental capacity? If yes, please describe. YES ___________ NO ___________ 3. AGENCY PROCEEDINGS: CIVIL LITIGATION: In the last five years, have you been, or are you presently a party of interest in any administrative agency proceeding or civil litigation, including any action regarding a professional license? If yes, please provide details. YES ___________ NO ___________ 4. AGENCY PROCEEDINGS AND CIVIL LITIGATION OF AFFILIATES AND FAMILY: In the last five years, has any business in which you, your spouse or partner, any member of your household or other close family members or business associate are or were an officer, director or partner been a party to any administrative agency proceeding or civil litigation relevant to the position to which you have been appointed? If yes, please provide details. (With respect to this question, you need only consider proceedings and litigation that occurred while you, your spouse, close family member or business associate were an officer of that business.) YES ___________ NO ___________ 5. LEGAL PROCEEDINGS: Have you ever been a party or otherwise involved in any legal proceedings ­ civil or criminal? Include all legal proceedings in which you were a party in interest, a material witness, the subject of a complaint, were named as a co-conspirator or co-respondent, and any grand jury investigation in which you figured as a subject, or in which you appeared as a witness. Do not list proceedings in which you were merely a nominal party where no allegations of wrongdoing were alleged against you. YES ___________ NO ___________ 6. BUSINESS RELATIONSHIPS/LOBBYING ACTIVITIES: Describe, on a separate sheet, any business relationship, dealing or financial transaction which you have had during the last five years, whether for yourself, on behalf of a client, or acting as an agent which you believe may constitute an appearance of impropriety or resulting in a potential conflict of interest in the position to which you want to be appointed. If none, please state. Also, are you, or have you at any time, been a registered lobbyist? YES _________ NO __________ 7. CITATIONS: Have you ever been cited for a breach of ethics for unprofessional conduct, or been named in a complaint to any court, administrative agency, regulatory body, professional association, disciplinary committee, or other professional group? If yes, please provide details. YES ___________ NO ___________ 8. CURRENT CHARGES: Are you now under charges for any violation of law? If yes, please provide details. YES ___________ NO ___________

Page 1 of 2

Vetting form

Commonwealth of Virginia

9. CONVICTION: Have you ever been convicted of or entered a plea of guilty or nolo contendere or forfeited collateral for any criminal violation other than a minor traffic offense? (Minor traffic offenses do not include the Virginia offenses of operating under the influence of liquor, operating while impaired, reckless driving or the equivalent offenses in other states.) If yes, please explain. YES ___________ NO ___________ 10. CHARGES/ASSOCIATIONS: Has a criminal charge been brought against any firm or organization during your affiliation with it? YES ___________ NO ___________ 11. DISCRIMINATION: Has a complaint of discrimination on the basis of sex, race, religion, national origin, age or handicap ever been filed against you, or against any firm or organization during your affiliation with it? YES ___________ NO ___________ 12. CREDIT HISTORY: Have you ever experienced credit difficulties? Have you ever filed for bankruptcy, or encountered other severe financial difficulties? If yes to either, please explain the circumstances. YES ___________ NO ___________ 13. DEFAULTS: Are you or your spouse or partner now in default on any loan, debt or other financial obligation? Have you or your spouse been in default on any loan, debt or other financial obligation in the past five years? If the answer to either question is yes, please provide details on a separate sheet of paper. YES ___________ NO ___________ 14. OPPOSITION/ASSOCIATIONS: Do you have any expectations of any group or individual voicing concern about your possible appointment? If yes, please explain. YES ___________ NO ___________ 15. CONTROVERSY: Is there anything in your personal or professional life that would cause controversy for you or the governor during a public review of your candidacy or your service as a gubernatorial appointee? YES ___________ NO ___________ 16. MILITARY SERVICE: List rank, date and type of discharge from active service: __________ _________________________________________________________________________________ a. Discharge: Were you discharged from military service under anything less than honorable conditions? If yes, please explain. YES ___________ NO ___________ b. Are you a member of the Reserves or the National Guard? YES ___________ NO ___________ If yes, date obligation ends: _____________ 17. AFFILIATIONS: Please list, on a separate sheet of paper, each organization, club, association, or group that you are, or have been a member of, in the past five years. FOR HOLDERS OF "CITIZEN MEMBER" SEATS ONLY: According to the Virginia Code, section 2.22102, a "citizen member" must be a person who: (i) is not by training or experience a practitioner in the subject area of concern to the board or commission, (ii) is not the spouse, parent, child or sibling of such a practitioner, and (iii) has no direct or indirect financial interest, except as a consumer, in the subject area of concern to the board or commission. Do you, in any manner, fail to comply (or have questions or concerns about whether you do comply) with the Code for your appointment as a citizen member? If yes, please describe on a separate sheet of paper. YES ___________ NO ___________

CERTIFICATION
I, ________________________________________ (please print name), certify that all statements and representations provided in this statement and on accompanying materials and resume are, to the best of my knowledge, true and accurate.

Signature: Dated:

_______________________________________________________ _______________________________________________________

PRINT Full Name:______________________________________________________ Board Name: _______________________________________________________

Page 2 of 2