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Foster Care Advisory Committee


    • By the Governor
    • Selected from lists compiled by the Health and Human Services Committee


    • No pecuniary interest in the foster care system;
    • No individual employed by the Foster Care Review office, the Department of Health and Human Services, a county, a child-caring agency, a child-placing agency, or court;
    • Two members from local foster care review boards;
    • One member who is a resident of the state and represents the public at large;


    • March 31, 2015


    • Meet at least four times each calendar year;
    • Oversee the executive director of the Foster Care Review Office;
    • Support and facilitate the work of the office;
    • Term begins March 1, 2015, or as soon as confirmed

If you are interested in being considered for an appointment to the Foster Care Advisory Committee, please complete this application form.

Today's Date
Your Name (required)
Appointment Desired (required)
Please list any other Boards or Commissions which you are currently serving on or previously have served on.
Legal Residence (required) (house number, street name)
Zip Code
Business Address (house number, street name)
Zip Code
Home Phone (required) (Please include area code)
Business Phone (Please include area code)
Cell Phone (Please include area code)
FAX Number (Please include area code)
Email Address (required)
Date of Birth
Place of Birth
Name of Spouse
Congressional District
Name of Your State Senator
Have you ever been convicted of a felony or misdemeanor?
Yes No
If yes, please explain:
Are there currently or has there ever been any disciplinary actions, suspensions or revocations of any licenses that you have been issued by any agency of federal, state, or local government?
Yes No
If yes, please explain:
Could you or any member of your family be affected financially by decisions to be made by the committee for which you have applied ?
Yes No
Diversity Information
(To assist in the selection, you are asked to voluntarily provide information, which is necessary for statistical reporting purposes.
Under State and Federal law, this information may not be used to discriminate against you.)
Racial/Ethnic Background
Statutes require some board appointees meet specific employment criteria.
List employment beginning with the most recent experiences.
A resume or additional information is optional.
Employer Location Dates
Schools attended including High School:
School Location Dates Major/Degree
Additional Information
Please list additional supportive information about yourself, your experiences, and background,
including any board or commission you have served on in the past,
honors or awards you have received, and other volunteer activities.
List names, addresses, and phone numbers of at least three people who may be contacted for references:
Name (required) Phone Number (required) Address

If you have a recently prepared resume or biography, you may fax or email them to Brennen Miller:
Fax: (402) 471-2126 (Please address to Senator Campbell, attention Brennen Miller)
Email :


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