Dear Candidate,

You are being considered for appointment to a

senior position of public trust by the Governor-elect
of the State of New Mexico that requires a review
of your background.

The Governor-elect values honesty. It’s important

to be truthful and complete when answering these
questions. Honest answers are not necessarily
disqualifying. Failure to disclose information that
could undermine the confidence of the people of
New Mexico in their government is disqualifying
and could be cause for termination if the
information you provide here is later found to be
false, misleading, or incomplete.
In order to properly control and protect this
confidential information, please provide the answers
to the attached questions and any additional
background material related to these questions to:
Office of the Governor
Attn: Jessica Hernandez, General
Counsel
State Capitol Building, Suite 400
 Santa Fe, NM 87501

This information must be provided and a review

completed before you are offered a position in the
Governor-elect’s administration.

CONFIDENTIAL CANDIDATE
QUESTIONNAIRE
PERSONAL INFORMATION
1. Please provide your full name, county of
residence, birthplace, social security number,
marital status, and list all places of residence by
street address and community for the last ten years.
If you were born outside the United States, please
provide the basis for your citizenship or permanent
residency in the United States. If you are married,
please list your spouse’s full name and occupation.

Answer 1:

2. Please list all of the schools you have attended,

beginning with high school(s), and include the
approximate dates of attendance and degrees
earned.
Answer 2:

3. Please describe your overall health. Are you

currently receiving medical treatment for a physical
or mental condition or illness or have you received
any such treatment within the past two years?
Answer 3:

4. Are you now or have ever been addicted to the

use of any substance and indicate what treatment, if
any,-- you have received?

Answer 4:

5. In the past ten years, have you used any illegal

drug? If so, please explain.

Answer 5:

6. Are you a veteran of the armed services and, if

so, were you honorably discharged? If not, please
explain. Were you ever subject to a court-martial?
Answer 6:

7. Have you ever been a candidate for any local,

state or federal political office? If so, please list
positions and, if elected, dates of service.

Answer 7:

8. Have you ever been appointed to any paid or

unpaid local, state or federal position. If so, please
list the position, dates of service and who appointed
you.

Answer 8:

9. In the past ten years, have you ever been

employed or retained by any candidate, political
party, political action committee or non-profit entity
engaged in public advocacy? Please list.

Answer 9:

10. In the past ten years, have you volunteered for

any political candidate, political action committee or
political party? If so, please list.

Answer 10:

11. Please provide the names, addresses and

telephone numbers of three personal references.

Answer 11:

LEGAL INFORMATION

12. Have you ever been charged with a DWI or DUI

or any other criminal offense, other than a minor
traffic violation for which the fine was less than
$300 dollars? If so, when? Please describe the
outcome.

Answer 12:

13. Have you ever been charged, pled guilty to, or

convicted of any misdemeanor or felony offense? If
so, when? Please describe the outcome.
Answer 13:

14. Please list any lawsuits you or your spouse have

brought as a plaintiff or which were brought against
you or your spouse as a defendant or third party, or
in which you or your spouse have testified at trial or
deposition. Include in this response any arbitration,
mediation, contested divorce proceeding or other
domestic relations matter.

Answer 14:

15. Please list any claims of sexual harassment or

other workplace misconduct made against you or
any employee directly supervised by you, including
the resolution of the matter.

Answer 15:

16. Have any civil judgments or liens been rendered

against you? If so, please provide details.
Answer 16:

17. Have you ever been the subject of a restraining

order? If so, please provide details.

Answer 17:

18. Has an allegation of abuse or neglect ever been

substantiated against you? If so, please provide
details.

Answer 18:

19. With regard to each obligation of child support

and/or alimony owed by you or your spouse, please
state the following: Have any payments been made
late or have there been any lapses in payment?
Have any motions or court actions for modification
of child supportor alimony been filed or instituted?
Have any actions or motions to compel payment or
initiate collection of late payments and/or past due
amounts been filed or threatened? Have any writs of
garnishment been issued? If yes, please provide
details.
Answer 19:

20. Are you aware of any ongoing investigations by

any federal, state or local authority involving you or
your spouse or any business or entity which you
own or substantially control, or in which you or
your spouse have more than a 5% interest? If yes,
please explain.

Answer 20:

TAX INFORMATION

21. Have you filed all federal and state tax returns
that are now due or overdue, and are all tax
payments, fines, penalties and interest been paid in
full and/or otherwise finally resolved with the taxing
authority? If no, please explain.

Answer 21:
22. Has a tax lien or other collection procedure ever
been initiated against you or your spouse by federal,
state or local authorities? If so, describe the
circumstances and the resolution of the matter.

Answer 22:

23. Have you or any entity in which you held an

interest ever filed a petition in bankruptcy, or has a
petition in bankruptcy been filed against you? If
yes, please explain.

Answer 23:

24. Have you, your spouse or any business entity

which you substantially own or control been subject
to a fine of more than $500 by any federal, state or
local government entity? If yes, please explain.

Answer 24:

EMPLOYMENT INFORMATION
25. Please provide an updated resume, which
includes a detailed list of all present and past
employment from the time you completed your high
school education to the present. (You need not
include summer or part time employment while
enrolled as a full time college or graduate student.)
For each position, please include the date(s) of
employment, the name of the employer, the position
you held, and a brief description of your duties. For
jobs in the past five years, please provide the name
of your supervisor(s), and the supervisor’s contact
information.

Answer 25:

26. Please provide the names of all business

enterprises (corporations, firms, partnerships, etc.)
and all non-profit organizations with which you are
now, or during the past ten years have been,
affiliated in any capacity.

Answer 26:

27. Have you ever been fired or resigned in lieu of

being fired? If yes, please explain.

Answer 27:
28. Has any adverse action ever been taken against
you for misusing the funds or credit of any entity
even if the misuse did not result in a criminal or
civil complaint?

Answer 28:

29. In the last ten years, have you ever registered as

a lobbyist or other legislative agent to influence
legislation or administrative acts in any state or for
the federal government? Have you ever received
payment for acting as a lobbyist or legislative
agent? If so, please supply details.

Answer 29:

30. Are you a member of any licensed profession or

occupation? If yes, please specify the following:
the present status of each license; whether any such
license has ever been withdrawn, suspended, or
revoked; whether any disciplinary action of any
kind has ever been taken in connection with your
license. Please also list any applications for
professional licenses or certifications that may have
been denied, and the reasons for denial.

Answer 30:

31. Please list any article, column or publication

you have authored, individually or with others that
is likely to be controversial. Please provide a copy
of the publication if available.

Answer 31:

32. Have you ever testified (on your own behalf or

on behalf of others) before the New Mexico
legislature, or any administrative, investigative or
regulatory body of the State of New Mexico?
Describe the time period and subject matter of your
testimony.

Answer 32:
33. Please provide the names, addresses and
telephone numbers of three professional references.

Answer 33:

FINANCIAL INFORMATION

34. Please describe any formal or informal

arrangement you have made with any person or
business enterprise with respect to future
employment and explain any termination payments
or financial benefits that you will receive upon
leaving your current employment or thereafter
during the next two years.

Answer 34:

35. Do you, your spouse, or any business in which

you or your spouse hold 10% or more of the stock
or membership interests, have any relationship with
any federal, state, or local government or Indian
nation through contracts, consulting services,
grants, loans or guarantees? Do you know of or
anticipate future contracts? If yes, please provide
details.

Answer 35:

36. Are you presently an officer, director, partner,

majority shareholder, managing member or holder
of a substantial interest in any corporation,
partnership or other business entities? If so, please
list the entity and your relationship.

Answer 36:

MISCELLANEOUS
37. Have you and your spouse, both in your
personal and professional capacities, complied with
all federal, state and local laws and regulations
related to the employment of individuals?

Answer 37:
38. Please provide URL address of any websites
that feature you in either a personal or professional
capacity (e.g., Business website, Facebook, My
Space, etc.).

Answer 38:

39. Within the last ten years, have you sent any
electronic communication, including but not limited
to an email, text message or instant message, that
could create a substantial question as to your
qualifications to serve the public or that could be a
source of embarrassment to you, your family, the
State of New Mexico, or the Governor-elect if it
were published in the newspaper? If yes, please
describe to the best of your ability the substance of
the communication and the context in which it was
made.

Answer 39:

40. Is there any fact or circumstance in your

professional or personal life that creates a
substantial question as to your qualifications to
serve the public or which might compromise, or
interfere with your ability to so serve? If yes,
please explain.

Answer 40:

41. Have you ever been associated with any person,

association, group, or business venture that could be
used to impugn or attack your character or
qualifications for public service?

Answer 41:

42. Are there any other matters you believe the

Governor-elect should be aware of?

Answer 42:

Items to be Submitted in Separate Document(s):

1. Please include an updated copy of your resume.

2. Please attach a list of your references (three
personal and three professional).
3. Please attach any readily available copies
articles, columns or publications you have authored,
individually or with others that are likely to be
controversial.
I hereby declare under the penalty of perjury the
foregoing is true and correct to the best of my
ability.
Print Name:_____________________________
Signature:_______________________________
Date:______________________

Please mail the completed and signed application,

with attachments, to Jessica Hernandez at the
following address:
Office of the Governor
Attn: Jessica Hernandez, General
Counsel
State Capitol Building, Suite 400
Santa Fe, NM 87501

Please keep a copy for your records

Waiver of Confidentiality

The undersigned applicant hereby waives, until the

position applied for is filled, the benefits of any
statute, rule or regulation prescribing confidentiality
of any legal, administrative, criminal, financial, tax
or business records, including but not limited to the
candidate’s credit reports and criminal history.

The undersigned applicant hereby authorizes all

federal, state and local government agencies and
administrative bodies, law enforcement agencies
and financial institutions to release the candidate’s
confidential records, including documents, records,
files, or any other pertinent data, to the Governor-
elect's Transition Team and its designated agents or
representatives, and the Chairman of the Transition.

The undersigned applicant hereby authorizes the

Governor-elect's Transition Team and its designated
agents or representatives, and the Transition
Director, to communicate with any and all past and
present employers, personal and professional
references, and family members regarding any of
the information disclosed on the applicant’s
questionnaire.

The undersigned does hereby release and discharge

the Governor-elect's Transition Team and its
designated agents or representatives, and the
Transition Director, from any and all liability of
every nature and kind arising out of the gathering
and furnishing of information so collected and
received concerning the applicant. The undersigned
also expressly consents to the release of his/her
name and this form to the public in the sole
discretion of the Governor-elect's Transition Team
and its designated agents or representatives and the
Office of the Governor and its designated agents or
representatives.

/s/_______________________________________

Date: ______________________