2. First Name*
3. Middle Initial
4. Last Name*
6. Street Number*
7. Street Name*
8. City*
9. Zip Code*
11. Work Phone*
12. Home Phone*
16. Community/Commission Applying For*
18. Are you related to a current employee of the Court?*

    1. Yes

    1. No
19. If yes, give name and position
21. Have you ever been convicted of a violation of any law, other than a minor traffic offense? (DUI convictions must be disclosed.)*

    1. Yes

    1. No
23. If YES, Describe
27. Education
29. High School Education*
30. Post High School Education*
34. Employment History
36. Present or Last Employer*
37. Your Title/Duties*
39. Start and End Date of Employment
    Start and End Date of Employment Start Date

    —

    Start and End Date of Employment End Date
41. Previous Employment (list employers, position, dates of employment)*
43. REFERENCES: (List three persons not related to you who have definite knowledge of your qualifications for this position)
45. Person 1 - Full Name*
46. Person 1 - Phone Number*
48. Person 1 - Address*
50. Person 2 - Full Name*
51. Person 2 - Phone Number*
53. Person 2 - Address*
55. Person 3 - Full Name*
56. Person 3 - Phone Number*
60. STATEMENT: Please provide a brief statement as to why you feel you are qualified for this appointment. If you are seeking re-appointment, please indicate what your contributions have been to the committee/commission during the time of your service.*
62. I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that any false statements will void this application and any action based upon it. Further, I authorize the Court to conduct a criminal history check and have provided my social security number for that purpose.*

    1. Yes

    1. No
64. Submit by:

    Please return the completed application by May 26, 2023 to the Lucas County Common Pleas Court, Office of the Court Administrator, 700 Adams Street, Suite 300, Toledo, OH 43604

Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field