14. Certification Full Legal Name Date of Birth / / Texas Driver License or DPS ID# Are you a U.S. Citizen? Yes No Place of Birth Date of naturalization (if not a citizen upon birth) / / Ethnicity: (optional; check all that apply) White African American Hispanic Asian American Native American Other CERTIFICATION OF APPLICANT I hereby certify that the foregoing and any attached statements are true, accurate and complete. I agree that any misstatement, misrepresentation, or omission of a fact may result in my disqualification for appointment. I assign and hereby give the General Land Office full authority to conduct background investigations pertinent to this application. I specifically authorize the Texas Department of Public Safety to conduct a background investigation and to disclose the results of that investigation to the Commissioner or his authorized representatives. __________________________ Applicant’s Signature __________________________ Submit to: Date Region 15 Region 16 Region 17 East Texas Regional Houston-Galveston Area Golden Crescent Regional Planning Commission Council Planning Commission Davis, Wemple, Joe Brannan, 2210 Eastex Freeway P.O. Box 22777 1908 N. Laurent St., 6th Floor Beaumont, TX Houston, TX 77227-2777 Victoria, TX 77901 (713) 993-4514 (361) 578-1587 x 208 Region 20 Region 21 Coastal Bend Council of Lower Rio Grande Valley Governments Development Council John P. Buckner, Ron P.O. Box 9909 301 W. Railroad St. Corpus Christi, TX 78469 Weslaco, TX 78596 (361) 883-5743 (956) 682-3281
14. Certification Full Legal Name Date of Birth / / Texas Driver License or DPS ID# Are you a U.S. Citizen? Yes No Place of Birth Date of naturalization (if not a citizen upon birth) / / Ethnicity: (optional; check all that apply) White African American Hispanic Asian American Native American Other CERTIFICATION OF APPLICANT I hereby certify that the foregoing and any attached statements are true, accurate and complete. I agree that any misstatement, misrepresentation, or omission of a fact may result in my disqualification for appointment. I assign and hereby give the General Land Office full authority to conduct background investigations pertinent to this application. I specifically authorize the Texas Department of Public Safety to conduct a background investigation and to disclose the results of that investigation to the Commissioner or his authorized representatives. __________________________ Applicant’s Signature __________________________ Submit to: Date Region 15 East Texas Regional Planning Commission Davis, 2210 Eastex Freeway Beaumont, TX Region 16 Houston-Galveston Area Council Wemple, P.O. Box 22777 Houston, TX 77227-2777 (713) 993-4514 Region 17 Golden Crescent Regional Planning Commission Joe Brannan, 1908 N. Laurent St., 6th Floor Victoria, TX 77901 (361) 578-1587 x 208 Region 20 Coastal Bend Council of Governments John P. Buckner, P.O. Box 9909 Corpus Christi, TX 78469 (361) 883-5743 Region 21 Lower Rio Grande Valley Development Council Ron 301 W. Railroad St. Weslaco, TX 78596 (956) 682-3281
CCRAG-Application.docx