Waste Tire Management Enterprise Board of Directors Application

The Executive Director of the Colorado Department of Public Health and Environment (CDPHE) appoints members. Note that members of this Waste Tire Management Enterprise Board are not considered employees of CDPHE. Please complete the information requested below. Please provide a current resume with this application (You may redact information on your resume that identifies age, date of birth, or dates of attendance at or graduation from an educational institution).

Help in your language: Free language assistance services are available to you. To request assistance in Spanish or another language, please email cdphe_apcd_outreach@state.co.us. Please include the topic and “language assistance” in the subject line. Please also link to the specific information you’d like to access, if possible, such as a web page or document.

Ayuda en el idioma de su preferencia: ofrecemos asistencia en el idioma de su preferencia, sin cargo alguno. Si desea solicitar asistencia en español o en otro idioma, envíe un correo electrónico a cdphe_apcd_outreach@state.co.us. Indique el tema y la frase “language assistance” (asistencia en otro idioma) como asunto de su mensaje. De ser posible, incluya un enlace a la información que desea consultar, como la página web o el documento.

Contact information

First name

Last name

Street address

City

State

Zip code

Home county

Cell phone number

Alternate phone number

Email address

Please confirm your email

Preferred contact method

Call/Voicemail Cell Phone

Text Cell Phone

Call/Voicemail Alternate Phone

General experience

Please describe any education (or formal training), professional or personal experience (including volunteering) (why you want to serve on the board, what perspective you will bring, and what strengths you will apply as a board member).

Board Experience: Have you previously served on a board? If yes, can you please describe what experience you gained and how you will apply that to this board?

Memberships in Organizations And Offices Held (Indicate if Past or Present)

Please provide a current resume. (Note: You may redact information on your resume that identifies age, date of birth, or dates of attendance at or graduation from an educational institution).

References: Please provide the name and contact information for three references. None of the references can be persons to whom you are related. Ideally, two of the references will be from individuals that are you and your organization's customers.

Reference #1 last name

Reference #1 first name

Reference #1 phone number

Reference #1 email

Reference #2 last name

Reference #2 first name

Reference #2 phone number

Reference #2 email

Reference #3 last name

Reference #3 first name

Reference #3 phone number

Reference #3 email

Waste tire enterprise specific experience management: representation

If selected, will you represent the following entities (select all that apply).

A for-profit business

A nonprofit business

A county government

Other (please specify) Other (please specify)

Name and contact information of the entity you would represent.

Entity/company name

Represented entity's phone number

Represented entity's email

Per diem and reimbursement for reasonable and necessary travel expenses is available. Please know your employer may prefer that you do not receive a per diem or reimbursement, particularly if they cover your time and expenses. If selected and you want to receive per diems and reimbursements, we will work with you and may need to speak with your employer.

I reviewed the above information.

If employed by the entity identified, will your employer support your participation?

Yes

Please indicate which of these you will/can represent as part of the enterprise board (you can select more than one).

Please explain your experience with the recovery, recycling, reuse, and management of waste tires.

What is your overall impression of the waste tire industry in the state? What are some of the positives with the state management of waste tires? Where do you see a need for improvement?

Waste tire management enterprise specific experience: expertise

Please select all of your areas of expertise from the list below.

Management of waste tires

Recovery, recycling and reuse of waste tires

Sustainability

Compliance

Please describe your expertise in management of waste tires, and how you have applied your expertise.

Please describe your expertise in recovery, recycling and reuse of waste tires, and how you have applied your expertise.

Please describe your expertise in sustainability, and how you have applied your expertise.

Please describe your expertise in compliance, and how you have applied your expertise.

Waste tire management enterprise specific experience: interest

What are your strengths and how will your strengths benefit the enterprise board?

Why do you want to serve on the Waste Tire Management Enterprise Board of Directors?

Ability to serve: conflicts

Board members have a fiduciary duty to the citizens of Colorado. Section 24-18-108.5, C.R.S. This means board members must act in the interest of the citizens of this state when conducting board business. Statute may authorize a board member to receive a per diem or be reimbursed for necessary and reasonable expenses. Some employers authorize an employee to serve on the board and include that time and effort as part of his or her employment duties. This is acceptable; however, no board member can accept other or additional payment to vote or act on a matter pending before the board. Similarly, board members cannot act on matters where the member may have a direct economic benefit or substantial financial interest.

Section 24-18-102, C.R.S. defines “financial interest" as a substantial interest held by an
individual which is:

(a) An ownership interest in a business;
(b) A creditor interest in an insolvent business;
(c) An employment or a prospective employment for which negotiations have begun;
(d) An ownership interest in real or personal property;
(e) A loan or any other debtor interest; or
(f) A directorship or officership in a business.

Section 24-18-110, C.R.S. requires a board member to disclose the nature of any private interest that may impinge upon her fiduciary duty and the public trust.

Have you or your organization received funding (a grant, contract or rebates) from the CDPHE Waste Tire Program?

Yes

Do you or your organization have a current grant, contract or recently received a rebate from CDPHE’s Waste Tire Program?

Yes

Do you or your organization serve as a subcontractor or subrecipient on a current grant or contract from the CDPHE Waste Tire Program?

Yes

Identify any financial interests.

Identify any appearance of or actual conflict.

Please provide any other disclosures relevant to this board.

Have you or your organization been determined to be out of compliance with any federal or state environmental laws, rules or regulations currently or within the last 5 years?

Yes

If yes, describe the compliance issue(s), including any issued Compliance Orders or legal judgements, against you or your organization.

Enforcement actions may be discussed during meetings in conjunction with determining funding of grants or rebates. Currently being out of compliance with environmental laws, rules and regulations may impact you or your organization from receiving funds from the enterprise board. You may be asked to recuse yourself on any discussion or final votes pertaining to funding of grants or rebates. Do you understand and are you comfortable with this process?

Yes

Are you willing to update your list of conflicts and disclosures with the Board Administrator periodically?

Yes

Members are asked to review conflicts and make disclosures for every board meeting. You will also be asked to determine if other board members can participate after they disclose a conflict or the appearance of a conflict. Are you comfortable doing this?

Yes

Ability to serve: Board Guidance and Statutory Mandates, and Governing Documents memo.

Yes, I have read and understand the Board Guidance and Statutory Mandates, and Governing Documents memo.

Are you willing to comply with the statutory mandates governing board members and the enterprise as well as any bylaws or procedures adopted by the board?

Yes

Are you willing to redirect any inquiries concerning board business to the Board Administrator, and contact the Board Administrator when you receive a request that does not comport with the statutory mandates and governing documents?

Yes

Ability to serve: time commitment

Individuals serving on a board need to commit to reviewing the material to prepare for meetings, attend the vast majority of meetings (ideally only missing one or two a year), and participate in person or virtually. Meetings are typically at CDPHE’s main campus in Denver; occasionally another location is selected. Members may be asked to represent the board in an informational panel or at a conference. Members are also occasionally asked to join enterprise staff during field audits or invited to attend other events. Are you able to satisfy these obligations? Can you commit to an average of 10-15 hours per month?

Yes

If you are already aware of periods of unavailability in the next year or ongoing, please provide those.

Certification of these application materials

I understand that the Colorado Open Records Act may require that certain information contained in this application be available for inspection by the general public.

Yes

I certify that the facts contained in this application are true and correct to the best of my knowledge. I authorize the investigation of all statements contained herein and the references listed above to obtain any and all pertinent information personal or otherwise.

Yes

For purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name and date as an electronic signature equivalent to your signature on a paper copy of the form. As such, this electronically completed form bears the same rights and responsibilities as a hand-signed form. *

Signature date +

Thank you for your interest in serving in the board.

Accessibility statement and support page