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HomeMy WebLinkAbout09/12/2011 Item 018 MOHAVE COUNTY REQUEST FOR BOARD ACTION FORM FORMAL ACTION: FROM: Tom Sockwell CONSENT ❑ CONTACT /EXT: Elaine Donovan X 2713 RESOLUTION ❑ DATE: 08/18/11 OTHER ❑ BOS MEETING DATE: 09112/11 INFORMATION ONLY ❑ SUMMARIZE THE ISSUE & DESIRED ACTION CLEARLY /ATTACH BACKUP MATERIAL: Discussion and possible action RE: Accept resignation from Kristal Gibson of her term on the Planning and Zoning Commission, effective 07/01/2011. Review and appoint applicant Krystal Symonds of Golden Valley to fullfill the vacant term effective 09/12/2011 through 07/06/2013. RECOMMENDED MOTION: Move to accept Kristal Gibson's resignation effective 07/01/1 land approve the appointment of Krystal Symonds to the Planning and Zoning Commission, term effective 09/12/11 to 07/06/13. Reviewed and Approved By: / County Attorney 0 Human Resources E-1 Finance 0 County Manager Board Action Taken: Approved as Requested No Action Taken = Disapproved 0 Continued to ���TTT Approved with the following changes: Acknowledged receipt and referred to: Filing Information and Retrieval Filed Bid Filed Agreement BOS Resolution Filed Yearly Correspondence Filed Petition Filed Dedication Filed Land Sold Filed Land Acquired Filed Franchise ID Resolution Filed Improvement District moiled Other Z y am. Date Routed: W/ s i l CS Remo Additional Information: XC: 16 I IAhl Human Resources Department MEMORANDUM DATE: July 25, 2011 TO: Nick Hont, Development Services Manager FROM: Marcia Trylch, Human Resources Office Specialist 1� RE: Krystal Symonds — Background Check Completed The Human Resources Department has completed the required Background Investigation on the requested appointee to the Planning and Zoning Commission, and has found that they meet Mohave County's background requirements. With a copy of this letter to the Clerk of Board of Supervisors, I am forwarding the original application. A copy of the application has been attached herewith for your records. C: File Clerk of the Board V, CO MOHAVE COUNTY APPLICATION APPOINTMENT TO BOARDS OR COMMISSIONS ,p Please return completed application to: MOHAVE COUNTY CLERK OF THE BOARD'S OFFICE D1864 700 W. BEALE ST, P.O. BOX 7000, KINGMAN, AZ 86402 -7000 Phone: 928 - 753 -0731, Extension 4731 Fax: 928 - 753 -0732 TDD: 928 - 753 -0726 The application form must be completed in sufficient detail to allow comprehensive review and evaluation. Issuance or acceptance of this application form does not create an obligation in any manner for Mohave County. In no case shall acceptance of an application constitute assurance of consideration, and an applicant may be required to submit additional application information to be considered for appointment to a Mohave County board or commission. 1. POSITION FOR WHICH YOU ARE INTERESTED IN SERVING ON Check more than one if you wish): Board of Adjustment Board of Health Building Code Advisory Board Extension Advisory Board Industrial Development Authority Libra - Citizens Advisory Board Merit Commission Parks Advisory Committee Planning and Zoning Commission Self Insurance Retention/Employee Benefit Trust Public Land Use Committee Workforce Investment Board Trans ortation Commission Other Please indicate): Youth Council 2. s m o N LAST NAME FIRSf NAME MI 3. 3 h� Co /P1t y,e:c ,t? C ( %/PN y1t STREET ADDRESS CITY STATE ZIP MAILING ADDRESS (if different from above) CITY STATE ZIP 4. HOME PHONE: `ee 7/-7 9 3`11 ORK I ELL PHONE: 91X .2�6� 93(- 5 5. MESSAGE CONTACT: tA)e&jk,,✓_ `) 5nos)+t -7/07 /1/ '11w 93 9, 979,7 - NAME ADDRESS PHONE # 7. Are you a registered voter? )0 YES ❑ NO 8. Do you live in the County Limits? If YES ❑ NO 9. Do you live in the city limits? ❑ YES i% NO; If YES, identify which city: 10. Are you available for evening meetings? YES ❑ NO 11. Are you available for early morning meetings? YES ❑ NO 12. Are you available for lunch meetings? YES ❑ NO 13. Are there any days of the week you are not available for any meetings? ❑ YES 'X NO; If YES, identify which day(s) you are not available: ❑ MON ❑TUE ❑ WED ❑ THU ❑ FRI 14. If appointed, please indicate which address you wish your mail to be sent: ❑ WORK/BUSINESS $HOME Work /Business Address: 15. Have you been known to previous schools, employers or references by another name? ❑ YES g NO If yes, please provide name(s) 16. If you possess a valid driver's license, check the class number and complete the following: Commercial Driver's License (CDL): P4 A ❑ B ❑ C List Special Endorsements W -TAye !�/'��de 10-iu 4684Z�e Other Driver's License: ❑ D ❑ M MISC.- Please Specify: Driver's License State: A.7— 17. Have you ever been convicted of anv violation of the law including moving traffic violations? You must answer yes if you have any convictions, in any state, no matter how long ago, whether felony or misdemeanor, even if they have been set aside, vacated, pardoned, expunged, dismissed or appealed, whether or not your civil rights were restored, you successfully completed probation, went to trial, entered a guilty plea or a no contest plea? ❑ YES % NO If yes, please explain all convictions as accurately and completely as possible. Convictions will be evaluated in relation to the particular appointment to a board or commission for which you are applying for and will not necessarily disqualify you for an appointment (Attach additional sheets as necessary). PLEASE NOTE: Prior to considering an appointment to a Board or Commission, Mohave County will require you to undergo and pass a thorough background investigation for the purpose of having a criminal history review. Any false statement or omission will be considered falsification of your application and grounds for immediate non - consideration of an appointment to a Mohave County Board or Commission. EDUCATION & TRAINING 18. ELEMENTARY AND SECONDARY EDUCATION: Did you receive a High School Diploma or G.E.D.? 04 YES ❑ NO 19. COLLEGE AND TRADE SCHOOLS: NAME & LOCATION CREDIT MAJOR TYPE OF DEGREE HOURS DEGREE AWARDED G 60.,11 Sk• .- fc..l L 3 Busi�css J1✓�•njri.<.t- &;iAess /yle. ❑ YES JZ NO ❑ YES ❑ NO ❑ YES ❑ NO 20. List appointment - related licenses, registrations, certificates or professional memberships: (Copy must be attached if a requirement of the appointment for which you are applying) DESCRIPTION NUMBER / STATE ISSUING EXPIRES 21. MILITARY SERVICE: ❑ YES NO If "YES ", please complete the following: Branch of Service: Date Entered: Date Separated: Are you currently a member of a U.S. Reserve or National Guard unit? ❑ YES ❑ NO If "YES ", list current assignment: 22. EMPLOYMENT HISTORY: Beginning with your current or most recent employer (including volunteer experience), list your employers and volunteer service for the last 10 years of employment/service. Provide complete and accurate addresses of former employers and agencies to which you volunteered. Attach additional sheets as necessary. You may include a resume; however, the employment history section must be fully completed UNLESS YOUR RESUME PROVIDES ALL OF THE INFORMATION REQUESTED BELOW. MAY WE CONTACT YOUR PRESENT EMPLOYER? YES ❑ NO A. Company: iQ-e id, b. — Ca vic 'Tve, Phone Number: 9,0' ) 5� -9 6. 9 Address /City /State: /a�J .�.� �/r.�✓ 93 9y/ /, N yff 47- fGyi Start Date: /C/ OX End Date: /� e w Your Title: Duties (be specific): �e A/ e ms, W 3 u5ihe"s ^654; h A &jg pu - , "' o , - 101 4AWANO-A f �:Nr�.ve�'r, 7A1(e5 hF,�M �- e'i�n wV' / Ah�F Reason for Leavin : Name of Supervisor /Reference Contact: 59 A,,q A Phone Number: ( W ) '7L'7- 73 B. Company: )_bu; % ya.t - -T - we- Phone Number. jy.5 ) 33a - 5 6'7 Address /City /State: b #ijAwc, ±d cl,,, I�NItia� r�r $!W3 YO Start Date: 1999 End Date: 0 Your Title: M44',wo Duties (be specific): Reason for Leaving: YYtyiec✓ Axttva,a Name of Supervisor /Reference Contact: TAaii. -D je- Phone Number: (dYB )33.- - 566'7 C. Company: SoA?okow%e_ ftAAA;F Phone Number: &o ) 7ya ;dot' Address /City /State: 3.?6,5- CA-b Dn. au,A 144r S�.YSdY Start Date: 1994' End Date: Your Title: v9 A v,,- L' Duties (be specific): ` )nFvi.w 11LVC� -C yiwn -r�nrv- nir �uI475 ¢- ��/S' Reason for Leaving: v cti - �Wc Supervisor/Reference Contact: �, ' "�n %s Nu /yruJ Name of Su p � •D Sa,� l��sk' Phone Number: ( ) D. Company: Phone Number: ) Address /City /State: Start Date: End Date: Your Title: Duties (be specific): Reason for Leaving: Name of Supervisor /Reference Contact: Phone Number: ( ) E. Company: Phone Number: ) Address /City /State: Start Date: End Date: Your Title: Duties (be specific): Reason for Leaving: Name of Supervisor /Reference Contact: Phone Number: ( ) 23. Have you been fired, terminated, or requested to resign (instead of termination) from any employment or volunteer position for misconduct or unsatisfactory service in the past ten (10) years? ❑ YES )1 NO If yes, please identify the name of the employer or agency and explain the circumstances surrounding the severance of your employment or volunteer relationship: 24. List all civil actions in which you were a party, other than divorce proceedings: ❑ NONE Date Location Nature of action or proceeding Disposition /Court Action Cfl i1�uatl�x,' ,li,� r.� �lz�z - Ax aged uoyur_ 5i e/ ove �co'✓ > Day f e `Di5jr s -d 25. List any other experience, knowledge and /or skills that you feel would especially qualify you for the Boards or Commissions in which you are interested: x 1 e,,,sY.1Z1W A-, 14Ar d A'fiB 6 ". /tai &I4. , r A d/ &eogAr 'eL 3 St'10ar4e Ft -L y fls, — d c e^L, jde,v gee,- •� uu -i IjY c1 A iw /?�6li.ryf l�iy t9. >r` ot s,Ne-s3 !.� A M !<tJ2y &gigs -y Z?A4•, 26. Have you ever or are you now on any public Boards and/or Commissions or Committees? ❑ YES % NO If YES, please list the Boards /Commissions /Committees, including length of service: BOARD /COMMISSION /COMMITTEE LENGTH OF SERVICE DATES 27. In what way do you feel you will benefit the Public by serving on the particular Board(s) or Commission(s) you have selected in Question #1? ; "t, W-, - 'r _ digu Jaee� 7 H,4 tip VA's ` ., F VtWK it kit. _, �r' See .i q ¢A, Saa,? .o, i A& .4 O A*:. -!, NPp 'le'l ,e,'o� uz e/ 28. REFERENCES: Give names and addresses of three people, not relatives, who have knowledge of your skills, experience and abilities. NAME BUSINESS /OCCUPATION ADDRESS PHONE 1 t d (9 rf ) 3Y& N• tun *, ed Cu nz 1/0 W. Y-4 93 0v R7 N aE/ -Z !r. /3 2. .ear e �usn►r.rt, any : ►,wk (4 tl � �Iy�' Bw W i be 1 Artip, DWiJee' of-hi Eeu L &6 Yl 3. ,u j3.4) ePfL gas" d 04 ) ' F6va des 1 I READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN Application IS INVALID unless SIGNED BY THE APPLICANT I certify that the facts set forth on this application are true and complete, and I understand any misrepresentation shall be sufficient to remove my ap ation from consideration. Please Initial /Date: 7/y /il I authorize Mohave County and any agent acting on its behalf to conduct an inquiry into any information related to my application, which may include a criminal background check. If selected to a Board or Commission, all personal data (except Social Security Number) will become a matter of public record, subject to public disclosure laws pursuant to ARS § 39 -121. jlp Please Initial /Date: J '7AV11 I certify that I understand, if appointed to a Board or Commission, I am subject to Arizona Open Meeting Law pursuant to ARS § 38 -431, and conflict of interest as outlined in ARS § 38 -503, and the requirements of ARS § 38 -201 (D) and (E) requiring compliance with th Federal Military Selective Service Act, 50 U.S.C. § 453, or that I am exempt from the same. Please Initial /Date: If selected, I will be provided specific information relevant to the above referenced Arizona Revised Statutes. The process of my selection may include interviews by the Board or Commission that I wish to join, as well as, an interview by the full Board of Supervisors, and an official vote for or against my appointment, in a regularly scheduled Board of Supervisors meeting. Signature (Do not print): Date: 7/'j // GAS hareIFORMSIAPPLITalent Bank Application- 02112003.doc A Board or Commission Member's Ethics Code As a Board or Commission member, I believe that the primary purposes of a Board or Commission are to achieve effective and wise guidance of the County through group thinking and action, to raise the standards of the Board or Commission membership and to improve the level of services to the County that supports it. I realize that mine is a County trust, that I represent all the people and that I have a duty to the County as well as to the Board or Commission. I pledge myself, therefore, to be sensitive to my obligations and relationships in this trusteeship. I subscribe to the code of an ethical person, remembering that ethics refers to what a person is morally obliged to do or not to do in a given situation. I believe that Board or Commission service can be an expression of democratic citizenship, signifying a willingness to accept County responsibility and the charge to preserve the popular control of American public services. Respecting the dignity and worth of the individual, I shall base my relations with people on their qualities as individuals without distinction as to race or creed or gender or color or economic or social status. I believe that a person's greatest possession, as well as his or her greatest contribution to society, may lie in the ways in which he or she differs from me, rather than in the ways in which we are similar. I shall accept these differences and try to build a useful relationship upon them. I uphold the principles of my organization, recognizing and assuming my responsibility to establish and administer the best possible program and policies for my Board or Commission. I shall learn its programs and objectives, give to it a fair share of my time and personal abilities, and keep a Countywide perspective knowing that, for sound County service, my Board or Commission's work must be coordinated with the total County. I promise to be loyal to my own organization and a good neighbor to other agencies. My attitude shall be one of cooperative open- mindedness and objectivity. In carrying out my assignments, I shall be professional in realizing it is not possible to lay down absolute rules for all situations. I shall be willing to think things through with other Board or Commission members, weighing alternatives and exercising good judgment in choosing among them. Name Date Signature G/Sh are/Forms/App I i cations