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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
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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