This form will serve as your application to the Department of Financial Services (DFS) to serve as a  Public Member or Alternate Member on the NYAIP Governing Committee for 2021.
 
This application will be provided to DFS, and they will contact you directly for further information if needed.

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* 1. I am submitting my Notice of Interest to  serve as a Public member or alternate Representative on the NYAIP Governing Committee for 2021:

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* 2. I am interested in serving on the Governing Committee in the following capacity:

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* 3. Please list all Trade Association affiliations:

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* 4. DFS is requesting you provide your qualifications and employment history for at least the past 5 years. Please insert the details below, which will be included in this application being provided to DFS on your behalf. 

Qualifications and work history:

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* 5. DFS is requesting you provide information regarding any complaints that may have been filed against you with DFS, and how they were resolved.

Please send this information directly to DFS at GCresumes@dfs.ny.gov

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* 6. Please provide any additional comments for DFS consideration:

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