swenot7 COV Boards ert Commiseons- Gots, Shery 2 All of lows. Applicant Profile — BIOGRAPHY DATA rofbe Title stast Mame : [Bates fae] “email Address aimee pis ‘AGA Account 10 ce Previous Addresses Provide addrase dolails forthe last wo previous locations you resided, Legal Residonco Addross 4 Lagal Residence Aeress 2 | Legal Residence Address Pale — state 2p Yes vt ‘rout Secupation Employer or Business Name i [Ferm Help ____ }BatesFarms, inc “Seimployer oF Business Adress [1759 E Ave Ieotion iar PERSONAL DATA * To assistus in providing balance and to meet our goal of increased divarsily within the membership of boards and commissions, we appreciate your response ta these questions. Under slate and federal law, this information may not be used fo discriminate against you. Black / African-American ® wnite/caucasian © tatine /tispano American Indian or Alaska ietive 2 Bi-Racial 1 © asian or Pacific Istancer taxed Race 1“oor GOW Boor anf Caminissions ales, Sherry spate of Bie (RAST NM, 4o2/24/1952 | 2, Do you have a permanent physical, sensory, or mental condition that affecss your major fife functions? yes ©No #2, Are you a parent or family member of a person with disabilities? “Yes @!No 3. Are you a Medea ecpient? Yes @No : "4, Are you 2 former Mecicald reciplent? Yes “No “48. Are you a provider of Medicaid-funded services? C}Yes © No {*6. Have you ever been on active duty in the U.S, Armed Forces? “Yes No 7. Are you a citizen of the United States? © Yes No. *B. Are you registered to vote in Iowa? ‘Yes ONo POLITICAL AFFILIATION ' epostical artation Te 1 None * EDUCATION HISTORY st schools attended, include high school. A current resume may be substituted for this section. Once you've completed tis form you wil be able to attach a resume in word) pal or it format. cs Ei -feimtMenth/vear,, Month/Year pDegre/afor “Taug {19708} aug v} (BS%Child Development (sta. yf ent Honth/Yenr *Degree/Major {Htigh School Graduate Previous School Name. city :Churdan EMPLOYMENT & VOLUNTEER EXPERIENCE List major paid employment and significant volunteer activities. List chronologically beginning with most recent experience. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, paf or rtf format. z ~ Syitis Position {licensed Bachelor of Social “stats unter jaa mene | ‘Eimplover/ Organization, [Greene County Medical Center ‘nadress {loot w Lincoinweywane GOV Boars and Commission - ates, Sorry ‘einploved/Orwsnization Stan woith/vear, End Wonih/vest_” itia/Postien iGreene County Depertment of Hun] Sep » 1984 ¥! | Jan | 1987 ¥} [Family ard Children social Wil avons Serene ais aera Ver Vouunteor Greene County Courhouse __ [veffersen ‘sotza Towa viNo vf sEmibover/Orsanintion.___ stare Manth/Year." endMatn/vear tite potion : iDeportment of Human Senfees | Jun v)t074v| | ov * P1876 7) (Regional Socal Wai) Address sag ae a 1 [Carrot 51401 “iGmployer/ Organization Stnit Month/Year Sha Nonth/voar resne County Department of Hun] Jun v Vf 1972 v} {Jul Ul 1972 v! ‘stole Weluntoer Nov! ‘Greene County Courthouse: [Jefferson PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A currant resume may be substituted for this section, Once youve completed this Form you wil! be able to attach a resume in word, pa or rt format Woath[voar “| Dec # ¥ 2014 | | Apr on 2017 v) [Regent _ State Towa ¥ __ "Office Hott =} fimember ‘State ~Fowa vl Jproiéssional Organization. {Scranton Telephone Board ‘Aires 4200 Main 1462 Ent toni 0 Ef W204 ¥) {chalman ‘professional Organization [Greene County Board of Hecith daross (1001 W. Lincoinway INTEREST IN APPOINTMENT “Describe in detail why you are interested background that supporis your interest Type or paste directly into {have been fortunate to fulfill a Board of Regent tern that will end April 36, 2017. |For the past two years, Ihave been an active Board menber that has worked with honor | land ethics. Not only have T spent time with other board menbers and the board office ;stoff to learn as much as I can, I have attended professional development opportunities 7 ractice ideas to, Plus, I 4 with other Boards throughout the nations PROFESSIONAL LICENSES HELD r - sespiny Date Professional iconses Held__ (inn(ddporv) {Licensed Bachelor of Social Work (1731/2010 popup iow pevestaplenn22 v4sor GOW Beers and Cemmnesion - ates, Serry teeued Year Expiry Date Professional Licenses Held aia nnd. (mmtddivynn) i zi a L } i‘yano17 GOV Bonds and Commission - Mushstant Kateen S Search All of owa.gov, Applicant Profite BIOGRAPHY DATA Prame/Titte seirst Nome i ¥ fiCathieen fome Phone : Gail Bhone vamgueaterti (hen Previous Addresses Provide address detaile forthe last to previous locations you resided. Legal Residance Address 1 Legal Residence Addrose 2 { ] chy state Zip |[Please Choose Lagat Residence Aldrss 2 | Please Choose © Lega! Residence Address 1 eee eee State paetice |[ Please Choose [Please Choose ¥ Your Seciipation Employeror Business Name | Retire ' ] “Eniployet or Businaas Addvess ~~ Eraplayor or Business Address, ine 2 i E } iy a county 7 i Please Choose ¥} Celt Phone Iiorie Phone (008300030000, 200 PERSONAL DATA * To assistus in providing balance and! fo meet our goal of increased diversity within the membership of boards and | commissions, we appreciate your response to these questions. Under state and fecoral law, this information may notbe used t discriminate against you. © etack/attican-American @ white/caucasion tntina/ttispane (Cy asian or bacifie tstander American . > ptixed Race © otner:|scot GOV Boards and Commissions - Mutated Kathleen S pate of Birth: eee ll (mm?sd/yvs) Gender: | Female 1405/1947 PL, Do you have a permanent physical, sensory, oF mental condition that affects your major life Functions? Oves Ginlo Fs Are you @ parent or family member of person with disabilities? (Yes No "#3. Are you a Medicaid recipient? ves No $76, ave you a former Meeald repent? C¥es No 5, are you a provider of Metcaldtunced serves? Yes @ No 6, Have you ever been on ect diy inthe U.S, Armed Forces? Yes ® No "7, re you a cizen ofthe United States? Yes CN #8. Are you registered to vote in Iowa? Yes C No POLITICAL AFFILIATION | Political Affiliation EDUCATION HISTORY List schools attended, include high school. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format, ae ra : tra “Most Recent Schootitome _____._ $Stprt Month(s University of Nosthem Jowa ~Fdun_¥ 9/1983 + cee (Ed educational Aamiaaoe sey {Geta Fas] stare Momh/Yoa Huan vl 1977 *ctty a ‘state [Cedar Fails | (towa End a {start Month/vear Month/Year —*Degres/Hajor._ May 7) = /1969 | Add more EMPLOYMENT & VOLUNTEER EXPERIENCE‘wanoir GOV fords and Commissions - Mulhall Kathleen S List major paid employment and significant volunteer activities. List chronologically beginning with Most recent experience. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format. fs ‘Fie Boston ‘Line-Mar Community School Dist’ Jul © 4 2003 7 [Superintendent Address . ic : State Voluntear [2999 North ‘oth Street (Marion “51902 Vowa | {Eepbrecfraeiatn, stot entn/Yent_ a ontnvaar Tren Indian Praitie CUSD 204 Touts} 1996 v} {Jun_v |)! 2003 #} [Assistant Superintendent-Ins] Addross. : “ty wo State ‘Volunteer |P.0. Box 980 ]Napervite tines vl PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format. Stote ‘i “Please Choose} INTEREST IN APPOINTMENT » Describe in detail why you are interested In serving on a stale board or commission. Include information about your background that supporis your inierest. “Tyme or paste directly into b fis a career educator and active citizen, T have had wary opportunities to bea part oF =| |alfferent committees and initiatives that have worked for the betterment of the lenoloynent experiences, 1 could bring a unique perspective to state-wide boards, [especially those that deal with education. As yas aseciety, | PROFESSIONAL LICENSES HELD “=Professional Licenses Held {Professional Administrator ; ~"Stgeued Yea? SExy Date Professional Llcenses Held ww, (rm ad/vO) [Evaluator 1 je0t0 113012045 ]svesn0r7 160V Boards and Commissions - Gada, Rene Search Ail of fowra gow. Applicant Profile BIOGRAPHY DATA ‘brotix/Title First Mite anitial stast Name, {Gada [Previous Addresses Provide address details forthe last two provious locations you resides. Hil Legal Residence Address 2 ae county, [Please Choose * Eilione PIEXIO000.. pnb PEREIRA, | PERSONAL DATA ‘ | + waustusn pov blnce nto metoucaletineabd vr witin be member of boas ar ae cys vogonso Wes questons Une stan cron es anatomy rite | ose ccna aosinstyou- {© ptacksarrican-american ® white scaucasion | © Asian of Pacific tstander © american Indian or Ataska Native © Bi-Raciat © Latino stispane: Wisvesrow7 1G0V Boats are Camsmissions - Gata, Rene “Dato of rth: ae vemm/da/yyyy). cena | losi26re7t © 1, Do you have 9 permanent physical, sensory, or mental condition that affects your major Iife functions? b Oves ®No i+2. Are you 2 parent or family member of a person with cisabiities? © +3. are you @ Medicaid recipient? Oves @ No {ca ave you 8 fermor Melcaid recipient? Yes @ No §e5, Are you a provider of Medicaid-funded services? *Yes © No |r6. Have you ever been on active duty In the U.S, Armed Forces? Yes “No D7, Are you a citizen of the United States? Yes \ No 8. Are you registered to vote in fowa? ® Yes S.No POLITICAL AFFILIATION | spouticat atitiation EDUCATION HISTORY List schools attended, Include high school. A current resume may be substituted for this section. ‘Once you've completed this form you will be able to attach a resume in word, pdf or rt format, End Moat Recent School Name, [eean univers fog | 108 ¥ eee [iNew Jereoy —Taug *}[9¢9°7] [Moy *} j Fes3 | pecity, eee i lod | ‘4 ioe a nd beprevious [ostomtigh Sctea I | *Dearee/ Maier, start Momn/vear Month/Year cs i Instruction & Curriculur Bo Soyshuboy @ Ealish Add. more 2aswesn017 GOV Boards src Commissions - Gala, Rene List major paid! employment and significant volunteer activities. List chronologically beginning with most recent experience. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format. Fed eignth Year | State Volunteer __| Please Choose vi Title/Pasition : ~ Volunteer Add more PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. 4 current resume may be substituted for this section. ‘Once you've completed this form you will be able to attach a resume in word, pol or rtf format. Grove Month/Year End Menth/Year office wots eens a } Lok aaa Zi state Adel INTEREST IN APPOINTMENT * Describe in detail why you are interostad In serving on a state board or commission. Incuce information about your background that supports your interest, Type orp: eee ae I find serving the conmunity very fulfilling, and I have been engaged in a variety of activities and volunteer organizations that have allowed me to do so my entire life | (see resume), Coupled with my service roles in the public arena, my professional i background in education over the last 26 years--in a variety of capacities--has afforded me a rich knowledge of emerging trends, basic needs, and a vision for the PROFESSIONAL LICENSES HELD stacucid Voor "Expiry Date oe. mn eae/yryy). {2000 fravaivzase issued Year” Expiry Date one) fmm/ad/yyyy) Add morewsran {GOV Booval end Commissiers - Gana, Renesrsn0rr GOV Bees and Cemmiesions- Mesionan, B earch All of owa.gow. Applicant Profile BIOGRAPHY DATA pew ee [Hotiman | Previous Addvesses Provide address detals fr the last two previous locations you resided. Legal Residence Address 1 Legal Residence Address 2 | [Piise cacse 7} EMPLOYMENT DATA pe roscoe _SEmployer of Businass Ni county | Potic vs Geil Bone (POOKIE OG) OOO 30000 PERSONAL DATA * To assist us in providing balance and fo mest aur gos! ofinereased diversity within ha membership ofboards and commissions, we appreciate your response to hese questions. Under siate and federal lay, his information may not be sed to discriminate against you. | © Biack/African-American ® white/caucasian © tatino/ Hispano © sion or Pacitic Islander ©) amenean angian or Alaska Native © sl-Racial | © mixed race © omnesspsrot7 1G0V Beards and Commissions -Hestmen, Bd =pate of Bia: fae a cron aii y nv) = cender: | Male 5 i976 EQ"beyou have a permanent physical, sensory or mental condition thet eferis Your major life functions? | Ores @ No (eaare you @paent or Fly member of parson wa dais? °)Yes Ono [*3. Are you Medicaid recipient? Ovyes ©No 4, Are you & former Mediicald recipient? ves No fs:weyora poe Hen funded services? ©ee © No 6. Have you ever teen on active duty in the U.S, Armed Forces? Oves ONo by. are you @ citizen of the United States? | @yes Ci Ne } ‘eg. Are you registered to vote in Towa? @ Yes Oo POLITICAL AFFILIATION rts un [Rep EDUCATION HISTORY List schools attended, include high school. A current resume may De substituted for this section. ‘nce you've completed this form you wil! be able to attach a resume 17 word, pdf or rtf format. TqanMonh/vear Hoshyear — roasre/¥nior. ay [Pressing 7 a 1 Month/Yoar Month/Year *Degree/MAiOE onsen a ryizony) [Ma fre Nain UE - ton Sea ses fice ff aoot e] [Sep 7} lemameey ‘Medical Techocian | (2004 fecity_. eeet uestatown | End Monti /yoar Dec ¥) an‘yesa0%7 GOV Boer ds rl Commissions - Heinen, OJ EMPLOYMENT & VOLUNTEER EXPERIENCE List major paid employment and significant volunteer activities. List chronologically beginning with most recent experience. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in wore, pdf or rtf format Sedinn(vese Sheree acon TE] etc Research Cortina] ears abntser Nowa No *) ‘Start Bnnan eee ead Hoan Wear” ile /Pesivion + }/ 2005 *} [Mar v)|2011 »] [CEO. aaa] ae ‘State i Votunteer {soda owe i No *] sini fed ionthvenr_.=T4le/Paghon fit {2006 ¥) fEmetoeney Reom Tesh [lowe vy ‘Stare flonth/Vear ~#Starefhonth7 a ini [May » } 2008 + *ki/sthn (ese a ‘slate PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pa oF rf format. Ena Month/Year ‘office Held fey —Tthandale ~ iSiart Month vear Toot rp{zom r} fo Add more. INTEREST IN APPOINTMENT * Describe In dolall why you are interested In serving on a state board or commission, Include information about your background thal supports your interest ‘Type or paste directly i — - Be Tam interested in serving on State boards and cormissions in order to serve and represent Iowans. My current professional and personal schedules don;t allow me to hold a political office but I feel serving on a board would be a superd way of getting involved in making Iowa a better place for all residents and visitors to this amazing | i |west? PROFESSIONAL LICENSES HELO ere fons emorne Medal Yon 1G0V Beards and Commissions - Hattmar. BY \iesued Vea! VD oy 202 | issued Yaar fom. i | seepy Dato tender fossuzora Expiry Date pease ‘Add more‘vesaore HO0V fos an Comission - Arorsn,Jeecb Ress Search All oflowa.gov, Applicant Profile BIOGRAPHY DATA Seiret Name, Lact Name, [Anderson |Home Phone (pgaes0 30000, ‘Previous Addresses Provide address details fr tho last two previous locations you resided. : Legal Residence Address 1 (Gio E Church St Legal Residence Address 2 zip ploverer SPO Box 160 county fatas CellPhone POLI D), (eae Lo. 1 eee) FFWork Phone ee” a, PERSONAL DATA * To assist us in providing balance and to meet our goal of increased diversity within tie membership of boards and commissions, we appreciate your raspanse ta these questions. Under stale and federal law, this information may nol bo used to diseriminate agains you. Biacksatrican-american ® wwite/coucasian © Latino /Hispano: or Alaska Native ©) Bi-Racial © Asion or Pace tstandor O amertonn sn © mixed Race © other:‘esto sev wt Conmir-Anrn J et spate of Birth: : al © fomneaayveNe). center: [Hale *) !{1oioar7984 1, bo you have a permanent physical, sensory, or mental concition that affects your majar Hfe functions? Oves @ No Je, are you a parent or family member of 3 person with disabilities? Yes ‘© No 3. Are you @ Meciceid recipient? Yes © No beg, Are you a former Medicaid recipient? “ves © No nS, Are you a provger of Nedlcaid-funded services? C1Yes © No 6. Have you ever been on active city in the U.S. Armed Forces? ‘.' Yes “No 7. Are you a citizen of the United States? Yes |. No FB. Are you registered to vote in Towa? © Yes ON POLITICAL AFFILIATION [epofitieal Affiiation EDUCATION HISTORY List schools attended, include high school. A current resume may be substituted for this section Once you've completed this form you will be able to attach a resume in word, poF or rtf format. 7 [ae ease! (2010 +] |ettost Recent School Name end Month/Year *Desree/Maor_ ; [Bachelor of Arts | Add more EMPLOYMENT & VOLUNTEER EXPERIENCE List major paid employment and significant volunteer activities, List chrenolagically beginning with most recent experience. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in ward, pdf or rtf format. E jane ‘Eid ont (vans. *Ytle/Positton "Sant Month] rn 21" I Volunteer 20svesno7 GOV Boards and Commissions - Anderson, Joccb Ross plowseTOraanitation ‘start iowth/Vicae.” Ghd Hanth/Vear.. *Tikle/Postion {Greater Dalles Counly Cecnomic 6! Nov * 2014 ®| | =] [Board somber } ca. TT state, Volunteer [West Bes Moines (50266 Towa ¥ Yes ¥! Add more PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in ward, paf or rtf format. fe a@tart Month/Year End Month/Year +O ifice Held sj itt [enacts ip. ae - 70002 District OF Columbia ¥ | Sioféssionat Organization, ______.“Start Month/Year, Ene onth/Veor “office Hekt flowa Cityicounty Manager Association {Nov + 2010 ©} | 2, #MamberProfessional Developme, ‘hes ses apeenieeet ane {sa 20809, INTEREST (H APPOINTMENT + Describe in detail why you are interested in serving on a stale board or commission. Include information about your ‘packground that supports your interest. “Type or paste directly into box. - poe Seepseneeeeceeeeerune las a city administrator 1 understand boardsmanship and its iaportance to the efficacy of jan organization. I believe that my education and vocation have developed my ability to see the many sides of issues and problens. I'm interested in using my knowledge, skills, fand abslities to work on delivering good governuent in the State of Lowa. issued Vear Expiry Date Co) fee a eee Issued Year Expiry Date fon)... — (rm/alddvi..sresreni? COV Boers art Commissions - Clue, Danie 4 Search All of owa.aow. Applicant Profile BIOGRAPHY DATA Profin(Titte Spire Nome idee aniiat “stage Name Ld Lasiiteeidonco neaivess 2 Celi Phone aes” [Previous Addresses {Provide address details for the last two provious focatians you resided. Address 1 Legal Residence Address 2 j TT) (tase Shanes) "Your Occupation... . Executive Vioe President pnsiocacectdasetony of bes tices] county, [Po ‘ eaifphene ~~ _OROIIIIOD. PERSONAL DATA | go assists in povdhg balance and to meet out ool ofincronse vers win the rambershipofbonds and “ommlasione wel spprecite your fosponse fo hose quoslone. Unde tae ane federal tw, his information may notbe | sod fo cscriminate against you | © siackatrican-american ® wnite/caucacian © tatino Hispano 1 O stan or Paci Islander © amevian tndion or Alaska Native Biacia | © mixed racesnes2017 COW Boe and Commission - Cite, Davi | spate of icth: Gea, MADLY, ‘Jowr4ri966 1. bo you have a permanent physical, sensory, or mental condition that affects your major life functions? Oves ® no |s2, are you 2 parent or family member of a person with disabilities? '/ Yes ‘© No }*3, are you 2 Medicaid recipient? O Yes @ No Fare you ferme ead ein” Yor “+5. Are you a provider of Meseak-unded services? Yes @ No Foe. awe you ever been on ective duty Inthe U.S. Armed Forces? Yes No 127. dre you acizen of he United States? “Yes No f ae fre. are you registered to vote in fowa? Yes | No POLITICAL AFFILIATION (cman nition [ep EDUCATION HISTORY List schools attended, include high school. A current resume may be substituted for this section, Once you've completed this form you will be able to attach a resume ia word, pdf or rif format. : “__aStartMontheYeor,Honth/Year Degree, ajor [University of lowa “Yaug e}[ 1988 v] [Dec sf (MBA | [ies See ahd “start Month/Year Month/Year “OegreedMaf@r Mose] [Aug ry [BBA faa] (1988 | i EMPLOYMENT & VOLUNTEER EXPERIENCE List major paid employment and significant volunteer activities. List chronologically beginning with most recent experience. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format. ‘Title (Position Employer/Organization Start Month/Year End Menth/Vear nid stave TREC LESTE {Please Choose ¥! |vesrott GOV Boer and Cammissens- Chute, Daniel ipiover taandéatiog ~~” “Bisse BonthiVear’ “End Saonen/vear_rlss/rostiton = june lal ! ‘mavens : ie site Volunteer nea e [Piesse Goce] ] Add more PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A current resume may be substituted for this section. ‘Once you've completed this form you will be able to attach a resume in word, pdf or rtf format: rofebsianal Organization Start Month/Year foi Month/Year._.Oes HeNd : pve) [gett [ede (eee | Ploase Choose”! es oes Nets amas L_ } inddress State a 7 _ ‘Please Choose | Add more INTEREST IN APPOINTMENT * Desoribe in deta why you are interested in sosvng on a stale board or comission. Inctude information about your backgtound that suppors your Inerest ‘Type ot paste deectly int a Beers see see eee | [as a graduate of a Regent institution, 1 have a strong belief in the vital importance : lof these schools to the future of our state and its citizens. We are in an unprecedented period in higher education history when costs continue to escalate apd ithe traditional higher cost delivery models are being challenged by new lower cost . channels. At the sane time, a first-in-class state university systes is a fundamental . a a es s state university § ist sieaas | | PROFESSIONAL LICENSES HELD a issued Year Expiry Date frm - fmm/de/vvwy)._. | { } a Yesued Year Bipiry Dato (om fdesoyvy. Add more.ssn (GV més ae Commissions - Forte Dal Search Al of own.gov Applicant Profile BIOGRAPHY DATA rack tome {Famer Seounty # . Emad Address GX ION OO) Provide address dolails forthe ast two previous locations yau resides. Legal Residence Addvess 2 cy ‘(oui es | [Webster EMPLOYMENT DATA sper ga __temnloyer or Business Name a ‘Boone Municipal Airport Employer or Busines Add ales, Like [aoa Sraidon Dive aay Sa county [Boone 450036 | [Becne al [Work Phone “Fax éeiiPhone 0x) a ise) PERSONAL DATA * To asciatus in providing balence and to mest our gosl of increased diversity within the membership of boards and commissions, we appreciate your response ta these questions. Under siaie and feceral law, tis information may not be ised to discriminate agains! you. | © pinck/atrican-American © whiteseaucasion © Latino /tispane © asian or Pacific tslander © american thin or Moska tative © BieRaciat Mixed Race{GOV Bose nd Commissions -Fernham, Dal E. saancer [iio] 1. Do you have a permanent physical, sensory, or mental concition that affects your major life Functions? Oves © No }+2. are you a parent or family member of a person with disabilities? ‘Yes No 63. Are you 2 Meclcaid recioient? Oves No fe. are you a ormer Mescad recpint? Yes No ps Are you & provider of Medicaid-funded services?“ a No (Ze Have you ever bean on actve dy the U.S, med Fores? Over No be7. Ave you a citizen of the United States? Ves No ie, Are you registered to vote in Towa? Yes CNo POLITICAL AFFILIATION | *Politicat attigation EDUCATION HISTORY List schools attended, include high school, A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format. End *pearee/Major oe (ProiAgonary Cnet ena Honth/Year eDegzee/Malor [Dec ) — [MS#Agronomy *pegrae ink start Month/Ye {sen =P oe ‘eprevious School Name __ [Arizona Stale Univesity state [BerApibusnese Nanoqanend |sresate 20V Beers and Commisslons- Fesrhiam, Dale EMPLOYHENT & VOLUNTEER EXPERIENCE List major paid employment and significant volunteer activities. List chronologically beginning with most recent experience. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdif or rif format. icine. —_—_-_ at gle, mati inn ; [Farmers Mutual Hall Insurance Cor| Sep ¥ }{ 2004 ¥] | Dec v j/ 2013 ¥| Vice President | 4 ese ge mee TEC cee ae Vakonege "West Bes Moines }50266 ‘ y 7} ‘mpiover7ouassleation, — Feta eae Ea Monga /voar. “Tite Pan é [Monsanto “Ysep 7 /{ 2001 ¥] [Aug 7} 2004 ¥| [Technology Development Maj iy a State ‘Yohintoer oo ‘Towa ey ‘start Moith/Veur “End Month/Year" SYile/Position v pf 1995} | Sep +} 2001 +] (Asst. Pratessor of Agronomy’ *] [Seo y}| 2001 +] [Asst. Profs aronemny| 7 oT _sstate Vatuntaer See Towa vl Seeaployer/Otaaateation ”\~” Start enh Veer "End Month/Year YY/8E/Postion ce iowa Stato University Extension [Jan v y[ 1995 7} | Jun» jy PROFESSIONAL ORGANIZATIONS List dates of membership and offices held, A current resume may be substituted for this section. Once you've completed this form you wil! be able to attach a resume in word, pdf or rif format. Sprokeadional Organization start Manth/Yaar_ office Held i [uen_*} [2009 v} 7] [Research and Business Develop} SEO wefty testssoneectoe Oo sstate - ~_ Pohnston ftowa ‘art Month/Year. End Montii/Vear “office Held rylise6 7] [PL] Ione Flows INTEREST IN APPOINTMENT + Deseribe in detall why you are Interasied in serving on a slate board or commission. Include information about your background thal suppor's your interest ty ‘directly Inte box ait es ceieE eee T want to be involved and heip wake an impact on the direction of Iowa's agricultural industry. Having spent most of my life and professional career involved in lagriculture, I have developed a great deal of respect and admiration for Towa farmers land agribusiness people, 1 have had the opportunity to view Tow agriculture from a variety of perspectives, I believe I have very diverse background professionally, andesr? PROFESSIONAL LICENSES HELO ‘professionatiicenscs ticls, 100V Boards and Commissions -Fatrisam, Dale tsued Vear one) om) nee) l BXbiry Sate fama) Add morensnos7 150V Boars end Commissions Fitzgibbon, Timathy arch AI of own. Applicant Profile BIOGRAPHY DATA Leet ame ries Moone {Fieoibeon iy ¥ [Timothy Email Address Cel Phove (Qo e200 | eee Fpreviows Addresses Provide audress delals fr the last two previous locations you resided, Legal Residence Address 2 state zp, “[Ptcase Choose |{_] [ease Grose » | ware y be r Employer or Business. Name. ‘National Counei! of Higher ication Rel rae Connecticut Ave, NW riba v 20005} { Pome Choose | eee eae Celi Phone OXIA HXAN). BOX IO 2000 nian: a ‘canna, ! ‘ logo ii ie PERSONAL DATA sist us in providing balance and to mee! our goal of increased diversity within the membership of boards and To ponse to these questions, Undor siate and federal law, this information may not be ‘commissions, we appreciate your | used to discriminate against you. | © Biack/African-American ®@ wnite/Caucasion © tatine/Hispano, © orraciat | © sion or poi sander © American indlan oF Alas Native | © Mixed Race © oxnesco (cov See Cents ins Tiny (ia 4 ‘epate of Birth: fmnn/da/ yyy) Petia fosro1964 We. Do you have & permanent physical, sensory, oF mental concition that affects your major fife functions? Oyes ine 42. Are you 2 parent oF family membor of @ person with clabities? Yes (No (#3. Are you a Medicald recipient? \ ves © No i7, Are you a citizén of the United States? Yes ‘.' No "8, Are you registered to vote in Towa? @ Yes "No POLITICAL AFFILIATION (ranean (ie EDUCATION HISTORY List schools attended, include high school. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format. end ‘start Month/Year Month/Year *Degree/Majer, {aug ¥ [1980 ¥] [May y) Seance ennay saga sop vp[ 1976 +] [Mey r) [Diploma [ese | Add more EMPLOYMENT & VOLUBTEER EXPERIENCE List major paid employment and significant volunteer activities. List chronologically beginning with most recent experience. 4 current resume may be substituted for this section, Once you've completed this form you will be able to attach a resume in word, paf or rtf format. iGingioyar/Orpaniation "Sin wih/vear End Wenth/Year ogee ae | _t Volunteer vilswoseot7 GOV Boards are Commissions - Fitzgibbon, Timety Emplovor/ovdsntzation Shait Menid Vent.” " Ghalstontiy/veor_ Titte/Postton i vl v4 | = é Steie Veluoteer |[Ploase Choose PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A current resume may be substituted for this section. Once you've completed this form you wil be able to attach a resume in word, pa or rtf format _ start ttonth/Vear | ~ End Month /Yoar ' Start Month/Year End Month/Year a INTEREST IN APPOINTMENT * Deserite in detail why you are interestas in serving on a stale board or commission, include infanmation abou your background that suppor your interest ‘Type or paste directly into box Tan interested in serving on a state board or commission as a way to give back to the ~ State of Iowa, my lifetime state of residence. My job is nationally-based and serving fon an Towa board or comission would allow me to comtribute and volunteer at a local level. I spent 15 years of my career working in state government (Iowa College Student Aid Comission) at _a senior staff level, so know first-hand the impact a eoard or ? PROFESSIONAL LICENSES HELD tested Year fuee.. L issued Year Expiry Date een. fmmlad/ynyy)...20 Bards vt Coramission - Harmer, Michael yon ‘yese07 arch All of lowa.qov. Applicant Profile BIOGRAPHY DATA ~eiest Nome _- Midas Baitad + [Michael {yen 3 ‘egal figsldence Addross2 re ny {Hammer aneeae eae ere ~ CR ODN... SOE OI) PERSONAL DATA ; | + To assistus in providing balance and to meet our goal of increased diversity within the membership af boards and ‘used to discriminate against you. © siack/atican-american Latino (Hispano Bi Racial © asin or Pacific Islander © Mixed Race other:sasr017 GOV Boards end Commissions - Sasmazer,Lyene M * sate of arts ot | (numeaatvnnn.. saat [08/06/196¢ {4.0 you have a permanent physical, sensory, or mental concition that affects your major life functions? | Oves © no [+2: Are you a parent or familly member ofa person with dsabtes? © Yes © No Are you a Medicaid recipient? Oves © No m fr, Are you a former Meticoid recipient? Ores Ono 5. are you a provider of Meslcai-funded services? yes @No fs. Have you ever been on active duty in the U.S. Armed Forces? O'Yes © No (7, Are you a ten ofthe Una tates? es No bs, ‘Are you registered to vate in Towa? © Yes ©'No POLITICAL AFFILIATION | spotiticat affiliation Dem EDUCATION HISTORY List schools attended, include high school, A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in wore, pdf or rtf Format spegree/major {indiana University ca a a —— = = End Month/Year ay oh IsPrevious, Bloomington Month/Year *Degree/Major_ lpreius Schoo ame [Bis Pollical Siena indiana University acihyYew | sonia tir Ty (ewe 1984 7 *stateLynne ‘wospotr GOV Boards ert Commissions - Sasmazs EMPLOYMENT & VOLUNTEER EXPERIENCE List major paid employment and significant volunteer activities. List chronologically beginning with most recent experience. A current resume may be substituted for this section. ‘Once you've completed this form you wil be able to attach a resume in word, pof or rtf format. ‘eimpioyer/Organlzation ~~ “Start Nonth/vear pecan Fe Position — West boty Bofors end fier Seie| Sep [20127] | * Pest, Board of kee dress [171 Highway 6 /miovi7o: ‘aaaross ait [111 West Seventh Strect ‘Employer/Orsanization. ‘Johnson County Historical Employer/Or Roy J. Carver Charitable Trust ‘naaress [202 lowa Avenue nd noni/Year*Title/Position [ i) {Program Director fe es PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A current resume may be substituted for this section. ‘Once you've completed this form you will be able to attach a resume in word, pdf or rtf format. Siar Wonth/Vear pee ‘ Add more INTEREST IN APPOINTMENT = Desa in ett wy you se lntresiad in seing ona nla oar orconiso. nue inbmraon about your ockgound at oupcte youre ; vs eget dey oo ae i yas oxmnts deca 0 jjcomiaaion service stons from Wy personal and professional = ty interest 2 pehucetion, beth at the Pela ane poseesecondory levels, "Ny academic 2) rae eeacsay dn political science, worve languages, Linguistics and pacer a cad dnd" doctoral: evel mor in the areo of Ridile Eastern stues, | specifically of the chancery language and political econony of the Ottonan Empire in_‘vosrot7 PROFESSIONAL LICENSES HELD ‘Professional Licenses Hold GOV Boas end Commissions Sasmazor, lynne tt Expiry Bate (m/e rye) L Expiry Date (mm/adre) L 1 aed Add morewstot7 GOV Beards an Commissions - Sloman, Caryn M Search All of lowa.gov. Applicant Profile BIOGRAPHY DATA \ rofix/Title Fest Name Middle znitiat “Last Name_ | {sie — state ell Phone Email Address (Previous Addresses Provide address details forthe last two previous locations you resided. >| vagat Residence Address 1 Legal Residence Address 2 cry Ic JC a ] city state zip tl Please Choose ¥}[__ EMPLOYMENT DATA peda : = : [tare ys No Nour Occupation jou currently employed? _-Employer or Business Name Se Employer or Business Address, Line ee county | Please Choose [Proaso Ghooso + fork Phone Phone Ext Fax CellPhone {CORDON {aaaaaas |. O Btack/ African-American ® white/caucasian © tatino/Hispane © asian or Pacific Islander © American Indian or Alaska Native © Bi-Racial O mixed race O otner:{ Inlpewfoperuplowa govlectepplican7705, WsGOV Bosrds and Commissions - Soman, Cerdyn Mt seonder: | Female “| feameterneee) [os25/1048 fF. Do you have a permanent physical, sensory, or mental condition that affects your major life functions? { ves @ no fa. Are you a parent or family member ofa person with deabiltes? Yes no fs. Are you a Mecicaid recipient? ves © No [r4- Are you a former Medicaid recipient? ves © No 5. Are you a provider of MedicaidUunded services? Ores @ No l+6. Have you ever been on active duty In the U.S. Armed Forces? O Yes @ No (57. are you a cizan ofthe Untd States? © #8. Are you registered to vote in Iowa? ‘9 Yes O No POLITICAL AFFILIATION *Pouttical afttation EDUCATION HISTORY List schools attended, include high school. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format fina onth/Year Month/Year lowa State University vy[ 1989] [Dec fecity state [Ames ices end cpm er [Dubuque Add more EMPLOYMENT & VOLUNTEER EXPERIENCEs2s017 GOV Bootds snd Commissions Siemenn, Carlyn Mt List major paid employment and significant volunteer activities. List chronologically beginning with ‘most recent experience. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, paf or rtf format. (Empiover/Oraan fini wy [St. Anthony Regional Hospital| Apr laddress —_ einerranecday es State ‘Volunteer ‘[towa ¥| ves v| herseresoracn as iy of Carol PlaningiZoing [Jen | 1000 ¥] hnadroas oe Ze aL “Title Position fin F201 >] Cee PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, pdf or rtf format. State | Please Choose INTEREST IN APPOINTMENT * Describe in detail why you are interested in serving on a slate board or commission, Include information about your background thal supports your interest. ‘Type or paste directly Into box ee Serving the City of Carroll, and St. Anthony Regional Hospital, as well as working witl Jstudents on the OMACC Carroll campus, as a full-time faculty member, has been both rewarding and challenging. If given the opportunity to serve the Branstad JAdministration, and the State of Iowa, on the Board of Regents, I believe the r lexperience I have gained, both in my volunteer i PROFESSIONAL LICENSES HELD ‘issiied Vear’ Expiry Date WY. fmmédd/yury).. (o1 ixProfessional Licenses Held [State of |A. Post Secondary‘wosnat7 GOV Boerde endl Commissions - TEWFIK, HAMED Search All of lowa.gow. Applicant Profile BIOGRAPHY DATA suast ome. (Tewrik | | as E 7) [Presse choose ¥] MPLOYMENT DATA (rare you moved? Yes: l2Vour Occupation Physi Employer or Business adaress [3010 Northgate Drive Welty a ee " iowa city + [52245 | —_ —— A — ae = “ pire nN a a 1 arte) PERSONAL DATA f | + To assistus in providing balance and to meet our goal of increased diversity within the membership of boards and commissions, we appreciate your response to these questions. Under state and federal law, this information may not be | used to Liscriminate against you | © Btnck/atrican-amertean © wnite/caucasian © tatino/Hispano | © asian or Pacific tstander D american -AIaska Native © BisRaciat © mixed nace © otner|‘iosrorr {GOV Boards aed Comnissions- TENFIK, HAMED | spate of nie pee idee el mn ddd) canter: [Male | fozrtai19a7 (2. Do you have a permanent physical, sensory, of mental condition that affects your major ie functions? | Oves @no fa. Are you parent of famly member of person with dsabitties? Yes © No f+. are you a Medicald recipient? Ores © No ‘na, are you a former Nedenid recipient? Oves Ono (5, re you 2 pros of Mela unded serves? Ove for. Are you a ltizen of the United States? © Yes ONo Fe.are you registered to vote in Iowa? ® Yes Wo POLITICAL AFFILIATION “Political Asitation EDUCATION HISTORY List schools attended, include high school. A current resume may be substituted for this section. Once you've completed this form you willbe able to attach a resume in word, pdf or rtf format. End *pearee/Major (mo Ikmost Recent School Name oe en/vear ‘Alexandria Univasiy,Calege Of adel Se Sep_¥}| 1952 ¥] be [Alexandria Leone sesslmeee iar ore pce “Ysen r)| 19507] [aun v} [High Soot caxicaie™ 7) [oat oe INoxanaia [ossiés Gea] Add more EMPLOYMENT & VOLUNTEER EXPERIENCE List major paid employment and significant volunteer activities. List chronologically keginning with most recent experience. A current resume may be substituted for this section. Once youve completed this form you will be able to attach a resume in word, pdf or rtf format. ‘End Wonti/vear ae. Gmployar/Organization fe | lool [Please Choose] Hine ananin nwa eu tne? | |‘esr GOV Boards and Commissions - TEWFK, HAKIED Employer/Grgsnization “Stare Momen/vear_ gna etonen/Year ___TRe/Position es eee eee s ‘ \Address, Ee eee : = State Volunteer (eee eg “fit disse PROFESSIONAL ORGANIZATIONS List dates of membership and offices held. A current resume may be substituted for this section. Once you've completed this form you will be able to attach a resume in word, te or rtf format. Bian Bit “Tia ffaorer) teen i a ste fet ae ;DesMoines Organiza in pate Peco edaion Oncologia dn ¥ 1988 Saeeeeenuaseee sey a iowa City ie gan Month/Year End Mor Proto’ Rasaion roe [u iter Ge . harass End Month/Year *offee Held { {Soi Employed INTEREST IN APPOINTMENT * Describe in deta why you are intorestd in sorving on a stato board or commission. Include information about your background that supports your intact. ‘Type or paste directly into box Have been in IA since 1972, Living in Joa City and working in Tova City since = 1972.Greatly interested in Quality of Health Care delivered to the citizens of Towa, guide physicians and protect the general public; in addition and as important 1 have great interest and involvenent in higher education ; being an academician for many i lyears and have been always involved with natters important to UI and college of PROFESSIONAL LICENSES HELD stisucd Year” sep Date OWW.. (men (anyW) 1974 lozow2019 ~asied Wear“ Bepiry Bate fren — fm ete) Add more Intpsfoparupiowa.govedteplicanl4012 a