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O f f i c e o f t h e G o v e r n o r U n i t e d S t a t e s V i r g i n I s l a n d s QUESTIONNAIRE FOR GOVERNOR'S NOMINEE FOR DEPARTMENTS, AGENCIES, BOARDS & COMMISSIONS PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE YOU COMPLETE THIS QUESTIONNAIRE. ALL questions must be fully and correctly answered and returned to the Office of Legal Counsel within seven (7) business days of your receipt of the Questionnaire. Do not submit a resume instead of this Questionnaire. If more than the allotted space on this form is required for a complete and full answer, please attach as many additional 8½ x 11 sheets as may be needed. At the top of each additional sheet put your name, "Office of the Governor, Office of Legal Counsel", and then reference the question number before each answer. The Questionnaire is in Format. Please complete all responses clearly in black font color. Responses are NOT to be handwritten. 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. Office of the Governor Questionnaire for Nominees to Departments, Agencies, Boards & Commissions 2 | P a g e NOMINEE’S NAME: SECTION I: BIOGRAPHICAL DATA 1. NAME: (Last) (First) (Middle) (Other) 2. SOCIAL SECURITY: 3. ADDRESS: Mailing: Residential: Business: E-Mail: Phone Number(s) – ________________________ (Cell) __________________________ (Home) 4. Length of Residence in the Virgin Islands: 5. Date of Birth: 6. Place of Birth: 7. Marital Status: Married Single Widowed Divorced 8. Full Name of Spouse: Mailing & Residential Address: Business, Name & Address: 9. EDUCATION Institution Dates Attended Degree Received Date Received Certifications VENETIA HARVEY VELAZQUEZ X Office of the Governor Questionnaire for Nominees to Departments, Agencies, Boards & Commissions 3 | P a g e NOMINEE’S NAME: 10. EMPLOYMENT 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 necessary, and reference this question number] Employer Dates of Employment Position Address/Phone # Supervisor 11. GOVERNMENT EXPERIENCE: A. List all federal, state, territorial or local government services, giving dates and type of service such as employee, boards, commissions, executive, legislative or judicial branches, consultant, voluntary service, part-time or honorary. [Attach additional sheet(s), if necessary, and reference this question number] B. List and attach a copy of all service contracts you have held independently or been a party to with the Government of the Virgin Islands. VENETIA HARVEY VELAZQUEZ Office of the Governor Questionnaire for Nominees to Departments, Agencies, Boards & Commissions 4 | P a g e NOMINEE’S NAME: 12. BUSINESSES AND FINANCIAL INTEREST: List all businesses (for profit or not for profit), real estate and trusts in which you have at least a 10% interest or control of assets or serve as an officer or member of a board with voting rights. [Attach additional sheet(s), if necessary, and reference this question number] 13. QUALIFICATIONS: What in your opinion qualifies you to serve the People of the Virgin Islands in the position which the Governor has nominated you? SECTION II: HONORS AND ACCOMPLISHMENTS 14. MEMBERSHIPS: List all memberships and offices held in professional, fraternal, scholarly, civic, charitable, and other organizations. 15. BOARDS, COMMISSIONS, TRUSTS, ETC.: List all government or private sector boards, trusts, or fiduciary responsible positions on which you have served or are now serving. 16. HONORS AND AWARDS: List all scholarships, fellowships, honorary degrees, honor society memberships, and any other special recognition for outstanding service or achievement. VENETIA HARVEY VELAZQUEZ Office of the Governor Questionnaire for Nominees to Departments, Agencies, Boards & Commissions 5 | P a g e NOMINEE’S NAME: 17. PUBLISHED WRITINGS: List all titles, publishers and dates of books, articles, reports, or other published materials you have written. SECTION III: CHARACTER 18. Have you ever been the subject of a grand jury, police, and department of justice or any legally constituted government authority, investigation anywhere or at anytime? YES NO If your answer is yes, please explain with details including date and location. [Attach additional sheet(s), if necessary, and reference this question number] 19. Have you ever been arrested in any geographical location for any offense, including traffic violations? YES NO If yes, please explain with details including offense, date of location and disposition. [Attach additional sheet(s), if necessary, and reference this question number] VENETIA HARVEY VELAZQUEZ Office of the Governor Questionnaire for Nominees to Departments, Agencies, Boards & Commissions 6 | P a g e NOMINEE’S NAME: 20. Have you ever been convicted of a felony or a misdemeanor? YES NO If yes, please explain with details including offense, date, location, and current status. [Attach additional sheet(s), if necessary, and reference this question number] 21. Is there now or has there ever been a judgment entered against you? 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 number] 22. Have you ever been a respondent in any labor dispute or discrimination 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 number] 23. Have you ever been named as a party in any hearing, administrative, civil, and criminal, including Equal Employment Opportunity or sexual harassment? YES NO If yes, please explain in detail, giving date, venue, agency, and the names of the other parties and the disposition. [Attach additional sheet(s), if necessary, and reference this question number] VENETIA HARVEY VELAZQUEZ Office of the Governor Questionnaire for Nominees to Departments, Agencies, Boards & Commissions 7 | P a g e NOMINEE’S NAME: 24. Have you now or have you ever been a member of an organization or an associate of an individual advocating terrorism, overthrow of a government by force or the advocacy or subordination of any ethnic group or individuals? YES NO If the answer 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 number] 25. Do you know of any individual, organization or group, which can be expected to oppose your nomination? YES NO If the answer is yes, please list the individuals, organizations or groups by name and give the details of your belief for their opposition. [Attach additional sheet(s), if necessary, and reference this question number] 26. Do you have any outstanding and delinquent monetary obligations to the Government of the Virgin Islands or any other public or private entity, including but not limited to, personal income taxes, business taxes, real property taxes (commercial or residential), business license renewals, trade name renewals, annual reporting fees, professional organization dues, child support, judgments, debt VENETIA HARVEY VELAZQUEZ Office of the Governor Questionnaire for Nominees to Departments, Agencies, Boards & Commissions 8 | P a g e NOMINEE’S NAME: Government of the Virgin Islands, includes but is not limited to the following departments, agencies and instrumentalities: the Bureau of Internal Revenue, Tax Assessor, Department of Justice Division of Paternity and Child Support, Board of Education, Economic Development Authority, U. S. Small Business Administration, Small Business Development Center, Police Department, Department of Licensing and Consumer Affairs, the Water and Power Authority, the Waste Management Authority, Department of Health, Department of Human Services YES NO If the answer is yes, please attach a detailed explanation of what outstanding and delinquent monetary obligations are owed, the reason for the delinquency, and the intended plan to bring the matter current. SECTION IV: CONFLICT OF INTEREST 27. Please explain your understanding of "Conflict of Interest" as it applies to the position to which you have been nominated to serve the People of the Virgin Islands. 28. Do you own a business or real estate, or are you a partner or shareholder or affiliated in any way to sell or provide goods or services to the Virgin Islands Government? YES NO If the answer is yes, please explain and give the name and location of these interest(s) and how you promise to remove yourself from any possible conflict. [Attach additional sheet(s), if necessary, and reference this question number] VENETIA HARVEY VELAZQUEZ   Office of the Governor Questionnaire for Nominees to Departments, Agencies, Boards & Commissions 9 | P a g e NOMINEE’S NAME: 29. Does any close relative or spouse have a business or real estate interest(s) as described in question 25? YES NO If the answer is yes, please explain and give the name and location of these interest(s) and how you propose to remove yourself from any possible conflict. (Attach additional sheet(s), if necessary.) SECTION V: JOB PERFORMANCE 30. In no more than 150 words, please outline in priority order your four (4) specific short-term and four (4) specific long-term goals and objectives you would employ to achieve the entity’s purpose and improve its service delivery system if your nomination is confirmed for this position. 31. Is there any additional information that you believe would assist the Committee on Rules and the Judiciary in processing your nomination expeditiously? VENETIA HARVEY VELAZQUEZ