Online Application

Personal Data
Upload resume
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 256 MB.
County in which you vote*
Congressional District*
State Senate District*
State Assembly District*
Are you registered to vote as a Republican in California*
- Yes
- No
Age
Birth date
MM slash DD slash YYYY
Business/Organization or Employer*
Title*
Have you ever been convicted of a crime (other than minor traffic violation)?*
- Yes
- No
Please explain
Why would you like to be selected for the Bergeson Series and what do you hope to contribute to the civic life of our state?*
Please answer in detail
What do you consider to be your most outstanding achievement in your life so far?*
Please answer in detail
How long have you been a registered Republican?*
Why did you register Republican?*
Are you a member of any Republican organization(s)? Please specify.*
Have you ever run for office or volunteered on a campaign for a candidate or ballot measure? Please explain.*
What are the top 3 issues (in CA) that elected officials should be addressing?*
How did you first learn about the Marian Bergeson Excellence in Public Service Series?*
Where do you see yourself in 5 years?*
Additional info you would like the Scholar Selection Committee to know:

Personal References

List contact information for 3 personal references and 1 political reference (must be a person willing to recommend you to the Bergeson Series who is currently involved in government/politics).

Reference 1
Name*
Title*
Home Phone
Work Phone
Cell Phone
Fax
Email*
Address
Street Address City State ZIP Code
Reference 2
Name*
Title*
Home Phone
Work Phone
Cell Phone
Fax
Email*
Address
Street Address City State ZIP Code
Reference 3
Name
Title
Home Phone
Work Phone
Cell Phone
Fax
Email
Address
Street Address City State ZIP Code

Applicant Agreement & Candidacy Request

I hereby request that the Board of the Marian Bergeson Excellence in Public Service Series consider my qualifications for candidacy. I understand that if selected, my attendance is mandatory at all, except in case of family emergency and that a second absence will result in my being dropped from the Series I understand that the Board of Governors of the Bergeson Series reserves the right to revoke membership or graduate status for actions or behaviors that it deems inappropriate or offensive at any time.

Further, I understand that if selected, I will be required to pay a registration fee of $250, as well as my transportation to and from all seminars. Finally, I understand that if I do not meet this required goal I will not be allowed to graduate from the Series.
Signature*
Phone
This field is for validation purposes and should be left unchanged.

Contact Information