Levee Improvement District 10 Board of Directors Application

Questions indicated with an * (asterisk) are required.

Personal Information
100 characters max
100 characters max
100 characters max
10 digits max
Home Address
100 characters max
100 characters max
100 characters max
5 digits max

How long have you lived at your current residence? *

Professional Information
List company, title, address, city, zip code, phone number, and company email. If Self-Employed and address and phone are same as personal residence, please indicate. If you are retired, please indicate.
300 characters max
List Employer, Type of Business, City/State and Dates (From and To).
500 characters max
List branch, rank, dates of service, date and type of discharge.
300 characters max
School (location), Degree, Year, and Major (e.g., University of Texas, Austin, Texas, BA, 1980, Liberal Arts)
300 characters max
List any job-related licenses or certifications that you have, the date you were originally licensed, the licensing agency and expiration date. If none, please put N/A.
300 characters max
List all business, professional, government and educational boards, commissioned organization and societies of which you are a current member and positions held. If none, please put N/A.
300 characters max

Have you been affiliated as an officer, owner, director, trustee, partner, advisor or consultant with any institutions (corporations, firms, partnerships, business enterprises, non-profit organizations, etc.) within the past five years which might present a potential conflict of interest with your requested appointment? *

Do you or a member of your immediate family own or have an interest or part in any business, company or entity conducting business of any kind with the levee district within the territorial jurisdiction of Fort Bend county, or any facilities controlled by Fort Bend County or any such district? *

Do you own real property, personal property, or financial holdings which might present a potential conflict of interest or appearance of conflict of interest with your requested appointment? *

Have you ever been disciplined, cited, or sanctioned for a break of ethics or unprofessional conduct by, or been the subject of a complaint to any court, administrative agency, professional association, disciplinary committee, or other professional group? *

Are there any pending complaints against you involving any court, administrative agency, professional association, disciplinary committee, or other professional group? *

Have you previously or do you currently serve as a member of any elected body? *

Have you ever been employed as a public employee of the state or local government? *

300 characters max
300 characters max
Please provide name, address, phone number and email address.
600 characters max
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