Workforce Development Board Application for Appointment • Sacramento Works

Applicant Information

Applicant's Name(Required)

First Last

Residence Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Residence Telephone(Required)

I am seeking a seat on the Workforce Development Board representing(Required)

Business (includes small business)

Labor/Workforce (includes apprenticeship programs, community-based and youth service provider organizations)

Education/Training (includes adult education and higher education)

Economic Development

State Employment Service

Vocational Rehabilitation

Other (includes transportation, housing, public assistance, and philanthropic organizations)

Business representiatives: To qualify for appointment you must be an owner, CEO, COO or other individual with optimum policy making authority or hiring authority for the organization you represent; and must represent businesses that provide employment opportunities that, at a minimum, include high-quality, work-relevant training and development in in-demand industry sectors or occupations in the local area.

Non-business representatives: To qualify for appointment, you must be an individual with policy making or decision making authority for the organization you represent. Please refer to Attachment A for specific membership requirements.

Applicant Information

Job Title(Required)

Name of Business/Employer(Required)

Business Address(Required)

Business Telephone(Required)

Business Fax(Required)

Email Address(Required)

Nature/Type of Business(Required)

Number of employees in your business(Required)

Major Job Classifications utilized in your business(Required)

Community Information

Please provide a list of all commissions, boards, or committees upon which you currently serve(Required)

Please identify any special areas of expertise and/or interests that you bring to the Board regarding economic development, business marketing, strategic planning, and/or special needs populations, including veterans, the disabled, migrant/seasonal farm workers, high risk youth, welfare recipients and/or dislocated workers(Required)

If you have any additional information that would be helpful in determining your nomination, please feel free to add it to this application(Required)

Potential Conflict of Interest Information

Does your employer/company provide goods and/or services to SETA or have any plans to provide goods and/or services to SETA in the future?(Required)

Yes

If yes to the above, please describe(Required)

As mentioned above, you will be setting policy for and allocating funds to many communitybased organizations, profit and non-profit corporations, school districts and other governmental entities (Program Operators). A list of current Program Operators is attached. Do you or any member of your immediate family have any affiliation with these Program Operators (i.e., ownership; employment; contractual relationships, including SETA-funded On-the-Job Training (OJT) program participation; commission, board or committee membership).(Required)

Yes

(Immediate family members are: wife, husband, son, daughter, mother, father, brother, brother-in-law, sister-in-law, father-in-law, mother-in-law, aunt, uncle, niece, nephew, step- parent or stepchild.)

Do you, or any member of your immediately family (as defined above), have any ownership interest in any commercial real property that is currently leased/rented by SETA or any of its Program Operators?(Required)

Yes

If yes, please describe such property by size and location and identify the name of the lessee/renter(Required)

If your nomination is approved, you will be required to file a limited conflict of interest form with the Clerk of the Boards prior to assumption of Board membership. Thank you for your interest.

Upload Your Resumé(Required)

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