Board ID# Position ID#
Tennessee Department Of State Division of Publications Open Appointments Notice of Appointment One copy of this form for EACH new appointment.
Board Name:
Appointed By:
Appointed Member is Replacing Previous Member Reappointment New/Reactivated Position
Name of Previous Member (if applicable):
Appointed Member Name:
Address :
Tn
City	State	ZIP
Phone:
County:
House District:
Senate District:
Sex:	Male Female
Race:
Term:	to
Position Qualifications: (Indicate all statutory requirements the appointee of this particular position must fulfill; e.g.: appointee must reside in West Tennessee, must represent private citizens, or must represent industry or teachers, etc.)
This form was prepared by:
Name:
Phone:
Email:
Date Submitted:
Office Use Only
Form Received: