USVI Public Records

Document text

1 PLEASE READ THE FOLLOWING INSTRUCrIONS CAREFULLY THIS QUESTIONNAIRE 5) Please do not hesitate to call the Office of Legal Counsel at Government House at (340) 774-0001 If you have any questions concerning thIs - Questionnaire. !.. 4) U Office nited St of the Governor ates Virgin Island S $W: BEFORE YOU COMPLETE 1) ALL questions must be fully and correctly answered and returned the Office ofLegal Counsel dithIn seven (7) business days of your receipt of thequestionnaire -- to 2) Do not submit a resume instead of this Questionnaire t 4) 3) If more thaftthe allotted space on this form Is required for a complete and full answer, pleaseftças many additlona 8) x 11 sheets as may be needed At top of each additional sheet put your name. “Office of the GoQènor, Office of Legal Counsel”, and then refen tht question number beforeach answer The Questionnaire IsPDF Format !Ieae complete all responses clearli In black font color oflses are NOT to be handwritten 14. l.enath of Residence In thivfrgln Islands: Phone Number(s) .-17t485.la (Cain S. DateôtBkth:.13i97a 6 PlaceofWrth csUfld,stcvIrdnmads 7. W.I Status: ........Marrled I - LFuUNameofSpousi:NIA Malllng&ResidentlalAddressr Busbiess, Name & Mdress 9. EDUCATiON Institution DateEAttehdêd 2!cct Date ReIved I. m of the Governor jtionnalm for NwNns to fls,..*n ZiPage - — NOMINEE’S NAME: . 5:. SECTION I: BIOGRAPHICAL DATA :4 1. NAME: (Last) IC: (First) (Ividdle) 4 (other) euge. Z.SOQALSECURIfl’; F A 32Johrj Brewers Bay, St. Thomas, VI 00802 Residential: BlJsiness:Same E.Mafl: uvpwsentM.edu . .b4orne) ... 4”. n.v...’, . . 4: _WWowed I DIVOFCed :1 ‘a Certifications VVI. 8197-5199 BSN 05199 . Emory L4ruv 08100-12101 MSN 12101 .iI. ifr Emory Univ )8102-0810E PhD 08106: Duke Univ. 7/06-7/07 07IO6 Postcfoc .. p UVI 8/95-5197 ASN 05/97 L Office ci Questlonnaim icr %imlne to Icards & rmilslonj 3lPage W MINItSNAMC. 10. EMftOYMP RECORD: Please list, In chronological order, your complete employment record for the past ten (10) years, beginning with the present or most recent POSItIOn. [Attach additional sheet(s), if necesary, and reference this question number) - Employer iilversity of’the Virgin islands Dates of Position AddresWPhone I Employment 0810112024- PresIdent - 2John Brewer’s Board of Trustees Bay - -- - - - - Florida Atlantic - 0710812019- Dean, Chief 777 Glades Rd. Russ Ivy & Bret University 07112)2024 , Exewove Boca Raton, FL Danflowicz :- --- j- - The University of - 0810512015- - Assistant 650 University Suzanne Prevost Abbame - 6fJ0I20l9 - Dean fi)r Blvd.: - - - - Racanrnh - 7* ,- ‘--;- - -.: 11. GOVERNMENT D(PERIENCE k list all federal, state, territorial or local government services, gMng dates and type of stc4 such as employee, boards, ?eonuIibons, executive, legislative or judicial branches, consultant, voluntary service, part-time or honorary (Attach additional shaet(sif necessary, and ,ference this question number) S?t LIst attach a copy of all service contracts you have held bidependendy or been a party to withtheGcvemmentofthevlrginlslands. 4tr - - - Supervisor I - - [the only govertinent experience I have had is serving as a Reviá,eree part of the Early C PWitiJa fr’ayn” m 4- Ma4i.snt tswftk, ! I*S#’I% - - t*t-:.t - Ar,, -- at - ‘C rr: S r .Tlceot t e Governor Qdjstlorrnaire for Nominees to Departments, Agencies, Boards & Commissions 4IPage 4EE’S NAME: i 12. ‘BUSINESSES AND FINANCIAL INTEREST: List all businesses (for profit or not for profit), real estate and trusts in which have at least a 10% interest or control of assets or serve as an officer neither of a board with voting rights. (Attach additional sheet(s), if necessary, and reference this etion number] C 5?Y?fl !$) A •1 j I, - - 13. QUALIFICAtIONS: What in youropinion qualifies you to serve the People of the Virgin Islands in the position whith the Governor has nominated you? • jje1ieve’that my 27yeáià’öf exjerience1ñ healthóare as a healthcare provider, inclUding a - a registered nurse, advanced practice nurse practitioner, and nurse educator. I completed my nursing training at the Roy L. Schneider Hospital and Medical Cente; during 1997-99. F” I also worked at Seaview Nursing Home and Rehabilitation Center as aregistered nurse. 3’.,, I also trained and worked as a registered nurse at Juan F. Luis Hospital ri St. Croix - and did some of my advanced practicp;nurse-practitionertraining-in.the VI. SECTION II: HONORS AND ACCOMPLISHMENTS .. ‘.t - .. 14. MEMBERSHIPS:”’ List all memberships and offices held in professional, fraternal, scholarly, civic, charitable, and otjorganizations. - — . -- . IMember, Sigma ThêttT&ilnatioriaI Hono? Society for M1nr j’hber.SocietYforNc1Dt’. ._r’-’ :rtr . t1HJ 1SJO,&J,COMMlSSloNS, TRusTs, ETC.: List all government or private sector boards, ‘- . trusts, orfiducii’ry responsible positions on which yoühave servedor areOow serving. - Member, Board of Directors, Boca Helpirfg. [Member, Board of Directors, Nursing Consc jijAN êflije?. Board of Directors, Sigma Theta Tau . - ) ,.; — —- . ( 16. HONORS AND AWARDS: list all scholarships, fellowshlp, hbnorary degrees, honor séclety memberships, and any other special recognition for outstanding service or achievement. ;. . - ::“-. fi Uuestlonnáe for Nnlnees to Depaim..g5, IenrJes, Borgis & Ccmmlss4ons SiPag. N0IqTN’ NAME: :.• r stinopjshed FeIjcm of National Academès of Pracdce — ‘Fellnw.nf Aflrtan Academy of Nursifl9 Amaflc Academy of Nursejradifioners 17. PUBLISHED WRItINGS: W other published materialsyou have written. I - - I — P - r — I-. -. I. ‘I -, 1 - Ust all tltlespiibhtiers nd dates of books, articles1 reports, or er heathoare tcptz . ,haYe more than 50 published papers, SpubHshed book chapters on the bplcs of HIV, COto I •‘- A SECUQJIII:Q4AI1ACTER4.L. 18. Have you ever been the subject of a grand jury, police, and department of justice or any legally constituted govemmentauthority, Investigation anywhere or at anytime? ._YES ifiO If your answer Isyn, please eiplaln with details Including date and location. (Attach additional sheet(s), If necessary, and reference this question number] t-. •1 I- 4 19. Have you ever been antsted b a.Wgeo€fl$i3tlocadon for any offense, Including traffic violations? YES If yes, please epbln with Øçtalls Inclu4lng offense, date of location and disposition. (Attach additional theet(sL If necessary, and reference tlis questIon nunter] g — . - • -. :- - - \ r 3-[ ‘‘ctt - •_.•_,- - ‘::t •1 YES XNQ 4f1 4 Is there now or has there ever been a judgment entered against you? i....NO -- . - If the answer is yes, please explain with details on date, location and disposition or current - status. [Attach additional sheet(s), if necessary, and relerepce this question numberl 1 1; r Ii: sto Departments, Agencies, Boards & Commissions 1lNFE’SNM%IK:’ ,r •, , Rave you ever been convicted of a felo?iv or a misdemeanor? If yes, please explain with details inclUding offense, date, location, and current status. [Attach additional sheet(s), if i%ciñary, and reference this question number] -tj - .; . : - •.-: .:7 ..t .J. J-.. - • - -. h p,,. - 22. Have you ever been a respondent inãn labor dispute or dis&iniination proceeding? YES NO If the answer is yes, please explain with details on date, location and disposition or current status. [Attach additional sheet(s), if necessary, and reference this question numberl ‘:‘t’-$” s”rr” ‘—I - -: , .4&4L’b I.,. “9 1 23 Have you ever been named as a party in any hearing, aaministrative, ci’N, includingEmployment Opportunity orsexualarnent? _YES If yes, please explain ineil, giviflg date, venue.agency, .odthe names of the other parties and the disposition [Attach additional sheet(s), if necessary, and reference this question numberl .t. - - ‘ir: Eq -v 3 .4 -: I - , Officeofg,eGove,nor -- Questlonjiafre for Nominees to Departnient Agencies1 Boards & Commlss1ons ilPage LME 3- I, r ---4 rN - - —- •1 1 -- -:‘ - Have you now or have you ever been a member of an organizetion or an associate of an ividual advocating terrorism, overthrow of a government by force or the advocacy or ordination of any ethnic group or individuals2 _YES XNO If the inier is yes, please give details of dates, names of organizations, names of individuals and all pertinent circumstances (Attach additional sheet(s), if necessary, and reference this question iiuffib’erT wvnt.- ‘1’4: :2.V4 25. -, I - -trj — - s - - t- . Do you know of any Individual, organization or group, whkti can be expected to oppose your nomination? ........YES i..J’iO, if the answer is yes, please list the IndMduals, organizationor groups by name and give the details of your beliefthefr opposition. (Attach additional shèe17recessary, and reference this question number] % - — - - - 26, Do you have an’/9ytstandin and inqueht monët’ obligations to the Government of the Virgin Islands or any other public or private entity, lncludjff but notjIYd to, pçrscqal income taxes, business taxes, real property taxes (commercial or residential), business license renewals, tJê name renewals, annual reporting fees, professional organization dues, child support, {udgrnents, debt N . - / -t *- ‘• , -Mf .ds, includes but is not limited to the folIoww departments, agencies reau of Jnternal Revenue, Tax Assessor, DePail nt of Justice Division of L’atern1t’rd1Iu’tIi..rSupoh, Board of Education, Economic DeveloPTE hority, U. S. Small cbusnessnistration, Small Bus,ness DevelopmenbCeflter, police Department, Department of eñslng and Consumer Affairs, the Water and Power Authority, the Wastc. •t Authority, Department of Health, Department of Humanrvid4 1 YES X.No ft;.r4. I If the answer is yes, pleaseikaich a detailed explanation of WIOUtstanding and delinquent r monetary obligations are owed, the reason for the delinquency, d the lrtèqdid plan to bring the matter cui?e’ñt j 47;: . SECFION Ill: CONFLICr oF INTE - 27’ Please explain your understanding of “Conflict of Interest” as it applies to the position to which oJiave been nominated to serve the People of the Virgin Islan C - •w:=-- ‘ . Iartments, Agencies, Boards & Ce, ‘I 1% a1 — — II—. [4e roknoWtdniiictrof interest thatwould1mtre with my sewicetsjcornrnittee. j1t1i: E .‘ H I 28. Do you own a business or real estate, or are you a pjttner or shareholder or affiliated in any way to sell or,provide goods or services to the Virgin fslinds Government?,. H. ..4YEs4o . If the ansvgr is yes, please exp and give the name aijfcation of these interest(s)’nd how you . promi ‘tobmoveV$ielf from any possible pnf1ict. additional sheet(s), if necessary, and referenc this questron’numbe,flc :‘ .s . rs. F E C. . . ‘ :i . . 4 .. .. .. .. . ‘ 1.. ‘ ‘ r PIIØ,:frL Office of the Governor - - - - Qtf4iinaire for Nominees to Departments, Agencies, Boards & Commissions - • 9lPage . - sr ‘EEtS NAME: •1 29. Doest’ñy close relative or spouse have a business or real estate interest(s) as described in - question 25? !_NO , a. . - If the answer is yes, please explain and give the name and location of these4çterest(s) and how you . Jpose to remove yourself from any iblé conflict. (Attach additiOn1LSheet(s), if necessary.) ________ ii h:tt . r- j -.?:4 w 1 4 -4 ‘: SECrION V:JOB PERFORMANC 30. In no more than 150 words, please outline in priority ord your four (4) specific’short-terrn 4 and four (4) specific long-term goals and objectives you would employ to achieve thentity’s tJ purposeañd’ improve its service delivery system if yo r. pomination is confirmed for this ‘ position:% ..4.L . 1 S port the heallhcare entitiep te VI, including on at : 4. r.. I !Z ‘fl-__ c . A\. 31. Is t’ re any additional information that you belie would assist the - tee on Rules and theiudiciain processingyournomiiiatiônexpeditiousl___________ .. .,--, I am passfhate about supporting efforts to improv e d imprtvin of peoIe i e US Virgin Islands. ‘- 4 Offi the Quegjonn to, NomTnes to Oepanmenl%Ictid0. Baacds lOlPage - t NOMINE€’S NAME: CERTIFICATiON: r This is to certify and affirm that all the statements contained tierein and in any supportkig documents or sdiedules or other such supporting documents Or schedule execut4at alater,date as a P&t or addudum to this document are true and correct to the jj of my icnotwi are made hi good f; faith. fr Sgned this 23 dayol Safiya George Nominee’s Name LPrlntCieartyI Sworn andW5!!bed b.f7 the this 23’ dayof To iss1onqxpirgs cfleU&wlu IAS,ü Lj /7 23j20- r. TI: j LA SHIVAOU I ilh)Ilfli, & I_v. WIWJe132GZ I r .5— Jread the following viry runy p4:f0 vu sign this d9(umept. 1. understand;hat the information given in this Ouestioflnall’t will be kvestlgated under a I applicable laws. 2. I understand that any false statement on any part of thisQuestlonflaire can be grounds for rejecting the confirmation of mynomination. 3. I hereby consent and authorize the release of lnformaon my character, background, ability, financial indebtedness and fitness to serve the residents ofthe United States Virgin Islands by all government enments and agencies; especially the Bureau.of internal Revenue, Tax Assessor, Department of Jistice DivisIon of Paternity and ChIid%jipport, of Educatlon, Economic Development Authority, U. S. Small Business Admlnlstxatlon, Small Bwlnessq’i’_ ment Center, Police Department Departnent of Licensing and Conswner Affairs, If applicable, employers, schools, all law enforcement agencies, and all other individuals and organizations, which may be deemed necessary, to authorized Committee on Rules and the Judiciary investIgators, Its staff and any other authorized employees of the Virgin Islands Governnlrnt as may be requIred. CERTlFICATiON ‘ k This is to certify and affirm that all the statements contained herein and in anylupporting ‘, document or schedules or’dthu such awporti documents or schedules executed at a later date as a part or addendum to this documeflt are true and correct to the best of my knowledge and are made In good faith. Slgnedthis dayor3i4..Jof SafiyaGeorge . . Nominee’s Name IPrint Clearly) ond”icried4efomethis• Notary Public oJt*eY-tscrrnn 1,Wnth- My commis*,Wejrpfre. k::; : Zj..:E’’” lrVfF — .,: Of&eoftheGor Que4jo,we for NomM to Oepamnents, Agende Boards & Commissions iliPage NOMINEE’S NAME ç 1n— I rr :: 4,I •1’’