IDPH Board Member Form and Application

Board Membership Form

(To be submitted with every board member)

State of Illinois

Illinois Department of Public Health

Name of Board (Use drop-down list)

Name Suffix (i.e., M.D., Ph.D., etc.)

Home Address

City Zip Code

Home Telephone

Business Name Occupation Title

Business Address

City Zip Code

Business Telephone Extension Mobile Phone

Fax E-mail Address

Preferred method of contact: ❏ Email ❏ Fax ❏ Mail

Driver's License Number

Sex Pronouns

(Optional)

Gender

(Optional)

Date of Birth

Race (African American, Native American,

White, Hispanic, Asian, or Other) (Optional)

Are you currently

a state employee?

❏

Yes

❏

Are you, your spouse, or any other family member living with you, required to be a registered lobbyist? *

❏

Yes

❏

If yes, name of family member, firm, association and/or organization:

Other Advisory Board Memberships within IDPH:

* No person required to be registered as a lobbyist under the Illinois Lobbyist Registration Act, or spouse or immediate family member living with such

a person may serve on a binding board. A binding board has the legal authority to make decisions or actions that must be followed.

A non-binding board makes advisory recommendations.

To be filled out by IDPH staff

Category of Member _________________________________________________________________________________________

Has resume or curriculum vitae been enclosed?

❏

Yes

❏

Recommended by _______________________________________________________ Date ___________________________

Deputy Director _________________________________________________________ Date ___________________________

Revised 9/19 Printed by Authority of the State of Illinois IOCI 20-165

For official purposes only. Information collected in this application will be used for the purposes of determining

eligibility to serve on IDPH boards or commissions. Answering or declining to answer optional questions will

not negatively impact IDPH’s review of this application. IDPH welcomes and encourages applications from

all persons regardless of race, religion, color, national origin, sex, political affiliations, marital status, physical

or mental disability, age, sexual orientation, or membership or non-membership in an employee organization.

Select a Board, Committee or Council Name

ISP 4-28 (11/07)

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

For a period of one year from the execution of this form, I _ _ authorize the State of Illinois,

Illinois State Police to conduct an investigation into all aspects of my qualifications and background. I also authorize any

individual, organization, or agency which maintains records relating to me to provide these records on request to any

agency of the Illinois State Police conducting such an investigation. This authorization includes, but is not limited to,

employment records, credit records, and criminal history records. The intent of this authorization is to give my consent to

full and complete disclosure of criminal records, internal investigation records, military records, records of educational and

financial institutions, employment and pre-employment records, background reports, efficiency ratings, and complaints. I

specifically waive my rights to written notice of release of information relating to prior disciplinary actions, as provided by

the Illinois Personnel Record Review Act.

I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving

this information; and I do hereby release such person(s) from any and all liability which may be incurred as a result of

furnishing such information whether from record or recollection. I further release the Illinois State Police, its agents and

designees under this release, from any and all liability which may be incurred as a result of furnishing such information.

Signature Date

Print Name Maide

n Last Name, former Married name(s) or

Other names used

Previous Address

Current Address

City / State / Zip

To process this form, the following information has been requested by the Illinois State Police:

Date of Birth

Sex / Race

APPLICANT BACKGROUND INFORMATION

Please complete the following question:

Have you ever been convicted of a criminal offense other than a minor traffic violation?

❏

Yes

❏

If your answer to the foregoing question is “yes,” please provide a detailed statement for each

such occurrence.

Signature

Date

Notice and Certification #l

The Illinois Lobbyist Registration Act (23 ILCS 170) provides, in pertinent part, as follows:

Sec. 3.1 Prohibition on serving on boards and commissions.

Notwithstanding any other law of this State, on and after February l, 2004, but not before that

date, a person required to be registered under this Act (Lobbyist Registration Act), his or her

spouse, and his or her immediate family members living with that person may not serve on a

board, commission, authority, or task force authorized or created by State law or by executive

order of the Governor; except that this restriction does not apply to any of the following:

(1) A registered lobbyist, his or her spouse, or any immediate family member living with the

registered lobbyist, who is serving in an elective public office, whether elected or appointed

to fill a vacancy; and

(2) A registered lobbyist, his or her spouse, or any immediate family member living with the

registered lobbyist, who is serving on a State advisory body that makes nonbinding

recommendations to an agency of State government but does not make binding

recommendations or determinations or take any other substantive action

The Illinois Lobbyist Registration Act provides in part that "the following persons shall register

with the Secretary of State as provided herein:

(l) Any person who, for compensation or otherwise, either individually or as an employee or

contractual employee or another person, undertakes to influence executive, legislative or

administrative action.

(2) Any person who employs another person for the purpose of influencing executive, legislative

or administrative action."

I, , certify that I read and have no conflict with section 3.1

of the Lobbyist Registration Act (25 ILCS 170). I further certify that should I be appointed as a

member of the , I will remain in

compliance with this Act (25 ILCS 170).

Signature Date

Notice and Certification #2

The Illinois State Officials and Employees Ethics Act (5 ILCS 430) provides, in pertinent part, as

follows:

Section 5-55. Prohibition on serving on boards and commissions.

Notwithstanding any other law of this State, on and after February 1, 2004, a person, his or her

spouse, and any immediate family member living with that person is ineligible to serve on a

board, commission, authority, or task force authorized or created by State law or by executive

order of the Governor if (i) that person is entitled to receive more than 7½% of the total

distributable income under a State contract other than an employment contract or (ii) that person

together with his or her spouse and immediate family member living with that person are entitled

to receive more than 15% in the aggregate of the total distributable income under a State contract

other than an employment contract; except that this restriction does not apply to any of the

following:

(1) A person, his or her spouse, or his or her immediate family member living with

that person, who is serving in an elective public office, whether elected or

appointed to fill a vacancy, and

(2) A person, his or her spouse, or his or her immediate family member living with

that person who is serving on a State advisory body that makes nonbinding

recommendations to an agency of State government but does not make binding

recommendations or determinations or take any other substantive action.

I, , certify that I read and have no conflict with section 5-55

of the State Officials and Employees Ethics Act (5 ILCS 430). I further certify that should I be

appointed as a member of the , I

will remain in compliance with this Act (5 ILCS 430).

Signature Date

CONFLICT OF INTEREST QUESTIONNAIRE

If answer is “YES” to any of the following, please explain YES NO

1. Have you or your company entered into any business or consulting

contracts with the State in the last three years? If so, list your partners (if any),

and identify all state agencies and departments with which you or your

company have had a contract in the last three years.

2. If you answered “YES” to question number 1, did you receive more than

7½% of the total distributable income under a State contract other than an

employment contract or did you, together with your spouse or immediate

family member living with you, receive more than 15% in the aggregate of

the total distributable income under a State contract other than an employment

contract?

3. Have you ever been named a party to any lawsuit or administrative

proceeding? If so, please list county and year filed.

4. Have you ever been arrested or convicted of a felony?

5. Are you aware of any investigation of your conduct by any federal, state or

local law enforcement agency?

6. Have you ever filed for protection under the bankruptcy laws?

7. Have you ever defaulted on a bank or personal loan?

8. Do you have any government-guaranteed loan outstanding?

9. Do you, or any companies in which you have a greater than 10% ownership

interest, currently owe any past-due state, local or federal taxes?

10. Is any member of your immediate family employed by the State?

11. Is there anything in your background, including any investments or real

estate holdings, which might create or appear to create any conflict of interest

with your appointment?

12. Is there anything in your background which, if it were disclosed, might

prove to be embarrassing to you or to the Governor?