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Office of Governor Pete Ricketts

Boards & Commissions

Application for Executive Appointment

If you are interested in being considered for an appointment to a Board/Commission, please complete the application below. If you would prefer to fill out the pdf format of the form, Executive Appointment Application, you may complete it and mail/fax/email the completed form to the address found at the bottom of the pdf.

  • Do not press the enter key until you are ready to submit the form. Press the tab key on your keyboard to go to the next field.
  • Please note that completed applications and additional application material that you provide may be subject to public information requests.

pdf icon  Boards & Commissions Descriptions

pdf icon  List of Unfilled Vacancies from Previous Year

pdf icon  2017 January - June Boards & Commissions with Positions Listed

pdf icon  2016 July - December Boards & Commissions with Positions Listed


 















Are you an United State Citizen or legally able to work in the United States?

Congressional District:


Are there currently or has there ever been any disciplinary actions, suspensions or revocations of any licenses that you have been issued by any agency of federal, state, or local government?


I hereby certify that neither I, nor any member of my immediate family, nor any other party having influence over me, has a material, personal or financial interest with any matter, under the discretion or jurisdiction of the board or commission for which I applied. I further certify that no other relationship, bias or ethical conflict exists which will prevent me from fulfilling my duties if appointed.

Political Affiliation (Some appointments require specified partisan membership; therefore we ask that you indicate your political affiliation):


Some boards/commissions have gender composition requirements. Although answering the following question is optional, it assists with meeting these requirements:


Employment:

Statutes require some board appointees meet specific employment criteria. List employment beginning with the most recent experiences. A resume or additional information is optional.














Education:

Schools attended including High School:











Additional Information:

Please list additional supportive information about yourself, your experiences, and background, including any board or commission you have served on in the past, honors or awards you have received, and other volunteer activities.



Areas of Interest:



References:

List names, addresses, and phone numbers of at least three people who may be contacted for references:











Please note that completed applications and additional application material that you provide may be subject to public information requests.

Some executive appointments are subject to confirmation by the Nebraska Legislature. One area of inquiry will be whether you or your spouse have a conflict of interest. An investigation into your background may be conducted by the Nebraska State Patrol prior to your appointment.

I hereby grant the Governor’s Office and the Nebraska State Patrol permission to obtain, and provide the Governor, any and all records pertaining to me from the Department of Revenue, Department of Motor Vehicles, Law Enforcement Agencies, credit bureaus, past and present employers, employees, business associates, affiliations, and acquaintances.

As a citizen of the United States or person legally able to work in the United States and a resident of this state, I will accept appointment if selected by the Governor. If appointed, I pledge my best efforts to resolve, before assumption of office, any conflicts of interest that would be inconsistent with my responsibilities as a gubernatorial appointee.


Although not required, if you would like to submit a resume and/or cover letter, you can upload the documents below:

Total file size for all files cannot exceed 17MB.



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When you click 'Submit Application' this form will be sent to Kathleen Dolezal, Office of the Governor, State Capitol, Lincoln, Nebraska 68509. Phone: 402-471-1971.

If you are having problems accessing or submitting this form please Contact Nebraska.gov.

All other questions should be directed to the Governor's Office.