Download Application Here - Fallon Tribal Development Corporation

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567 Rio Vista Drive
Fallon, Nevada 89406
Tel 775.423.6040 / Fax 775.423.6048
http://www.ftdc.us
FTDC Board of Director Application
Applicant Name:
Mailing Address:
Residence Address:
Date of Birth:
Social Security Number:
Tribal Affiliation:
Enrollment Number:
Daytime Phone:
Evening Phone:
Mobile Phone:
Fax Number:
Email:
Are you a Nevada Resident?
Employer:
Supervisor Name:
Employer Address:
Employer Phone:
Position:
# of Years with Employer:
Have You Ever Been Bonded?
YES
NO
If selected, do you authorize the Fallon Tribal Development Corporation and/or the Fallon
Paiute-Shoshone Tribe to conduct a full fingerprint background check on you?
YES
NO
If selected, will you submit to pre-appointment and random drug testing in accordance with
the drug policy of the FTDC and/or FPST?
YES
NO
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TTRRAAIINNIINNGG &
&E
EXXPPEERRIIEENNCCEE
1)
(submit resume and/or attach additional paper if necessary)
Educational Background. List both formal and informal education and training experiences.
Name and Address of School and/or Source
High School or
Equivalent Program
Mark Last
Year Completed
Did You
Graduate?
1
2
Y
3
4
N
1
2
Y
3
4
N
1
2
Y
3
4
N
1
2
Y
3
4
N
Subjects Studied and
Degrees Received
College
College
Post-College
Other Education
(formal / informal)
2)
Professional Qualifications, Work and Business Experience.
3)
Community Activities and/or Other Experience.
4)
Governmental Experience. Describe your experience with working with Tribal, Federal, and Local Governments.
5)
Tribal Experience. Describe your experience with working with Tribal Communities.
Tribal, Professional, Civic and Community, religious institutions,
neighborhood associations and any other groups. Please note if you hold an executive position, including Board of Directors.
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6)
Reasons for Appointment. Explain why you would like to be considered for appointment to the Fallon Tribal Development
Corporation’s Board of Directors.
R
REEFFEERREENNCCEESS
(please provide three (3) references not related to you)
Name
Address & Phone Number
Business/
Organization
Years
Acquainted?
C
CRRIIM
MIIN
NAALL O
OFFFFEENNSSEESS
Have you ever been convicted of any criminal offense or is there any criminal charge now
pending against you? (“Criminal offense/charge” means any felony or misdemeanor,
including driving while impaired, or any offense classified as “criminal traffic” – only traffic
offenses classified as and “infraction” is excluded.)
YES
NO
YES
NO
YES
NO
If “Yes,” submit a detailed written explanation in your own words describing the circumstances for
each offense/pending charge. Also submit a copy of the court judgment for any conviction not shown
on your criminal record report (or arrest warrant or bill of indictment from any pending charge).
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Are there any liens or unpaid judgments now outstanding against you due to your failure to
pay a debt?
If “Yes,” submit a detailed written explanation in your own words of the circumstances and your efforts
to pay, as well as the name of the judgment creditor or lien holder (i.e., the party you owe), the
amount and date of the judgment or lien and the current balance.).
B
BAANNKKRRUUPPTTCCYY
Have you ever filed for bankruptcy?
If “Yes,” submit a detailed written explanation in your own words of the circumstances, the date when
this action took place, as well as any other pertinent information regarding your bankruptcy
declaration.
C
CEERRTTIIFFIICCAATTIIOONN
I swear the information I have entered on this form is true to the best of my knowledge. I understand that if I deliberately
conceal or enter false information on this form my application may be rejected, I may be removed from the list of eligible
candidates, or I may be removed from the position. I authorize the Fallon Tribal Development Corporation and/or Fallon Paiute
Shoshone Tribe or their designee to contact present or former employers, employees, or other persons who know me to obtain
additional information about my skills and abilities. I understand that if selected, I will be required to provide the Corporation
and/or Tribe with additional information and documentation necessary to conduct my full background check as well as provide
documentation necessary for the operations of the Fallon Tribal Development Corporation.
Signature:
Date:
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