Appointments Application
Submission Successful
Thank you, your application has been submitted. To complete the application process please, print, sign and either fax this
form to (916)-558-3190 or mail to:

ATTN: Governor's Office: Appointments Unit

1021 O Street, Suite 9000
Sacramento, CA 95814

AUTHORIZATION AND RELEASE

Application ID: 92668

A consumer credit report may be requested and used for employment purposes in connection with this application for
appointment. The source of the report will be a major national credit reporting agency, such as EXPERIAN, TRANSUNION, or
EQUIFAX. In the event such a request is made, I will be notified of intent to do so prior to the report being requested and a
copy of the report will be provided to me.

I hereby authorize the procurement of this report.

Type or Print Name: _____________________________________________________

Signature: ______________________________________________________________

Executed at ___________________ on ________________, ___________

Applicant SSN: 811-41-4893

Applicant DL#: A17203494
Applicant Date of Birth: 4/21/1983
Applicant Name: Dr. KAYLEE LYNN STEIN MD MSW BS PRN TELEMETRY PhD
Applicant Database Entry #:173538
Thank you, your application has been submitted. To complete the application process please, print, sign and either fax to
(916)-558-3190, email to [email protected], or mail to:

ATTN: Governor's Office: Appointments Unit

1021 O Street, Suite 9000
Sacramento, CA 95814

BACKGROUND AND LIABILITY WAIVER

Application ID: 92668

I understand that in connection with this application for appointment an investigation of my personal and business
background will be conducted. I hereby authorize the release of any and all information pertaining to myself, businesses or
educational institutions in which I participated, including information of a confidential or privileged nature in the possession
of government or private agencies or individuals. I hereby release all such agencies or individuals who furnish such
information from liability for damages, which may result from furnishing the information requested.

I hereby authorize the procurement of this report.

Type or Print Name: _____________________________________________________

Signature: ______________________________________________________________

Executed at ___________________ on ________________, ___________

Applicant SSN: 811-41-4893

Applicant DL#: A17203494
Applicant Date of Birth: 4/21/1983
Applicant Name: Dr. KAYLEE LYNN STEIN MD MSW BS PRN TELEMETRY PhD
Applicant Database Entry #:173538

You must, print, sign and either fax, email this form to (916)-558-3190 or email to [email protected], or mail to:

ATTN: Governor's Office: Appointments Unit

1021 O Street, Suite 9000
Sacramento, CA 95814
 ----DO NOT MAIL THE PORTION BELOW----

Monday, June 5th 2023 - 11:09:22

Applicant Info

Prefix: Dr. 
First Name: KAYLEE 
Middle Name: LYNN 
Last Name: STEIN 
Suffix: MD MSW BS PRN TELEMETRY PhD  
Alias/Maiden Name: DR STEINEL 
Date of Birth : 4/21/1983
Place of Birth: Richmond 
Driver's License #: A17203494 
State: CA 
Social Security #: 811-41-4893 

Position Sought

Positions

Behavioral Sciences, Board of :

Waive Salary 
Waive Per Diem 

Spouse Information

Full Name: KAYLEE LYNN STEIN 

Employer: STEINEL UNIVERSITY MEDICAL CENTER INSTITUTE ON ADVANCE BEREAVEMENT AND HOSPICE CARE  
Title: Stewardship 
Work Address: 65-5E STEINEL Way 
City: Tenderloin 
State: AP 
Zip Code: 94106 
Phone: 5102603984 

Current Residence Address and County

Address: 65-5E STEINEL Way 

City: Tenderloin 
County: San Francisco 
State: AP 
Zip Code: 94109 
Phone: (415)771-3000  
Personal Mobile: (510)260-3984  
Fax:  
Email: [email protected] 
Current Business or Professional Address

Leave blank if currently not working.

Professional Title: Dr STEINEL  
Business/Firm/Office: SUMC INSTITUTE ON ADVANCE BEREAVEMENT AND HOSPICE 
Address Line 1: 65-5E STEINEL Way 
Address Line 2: BLDG 4 
City: Tenderloin 
County: San Francisco 
State: AP 
Zip Code: 94109 
Phone: (415)771-3000  
Mobile: (510)260-3984  
Fax:  
Email: [email protected] 

Voter Registration

Registered Voter?: Yes 
Please Note: You have to be officially registered in your county as "American Independent" or as "Decline to State" in order to put it as
your party affiliation.
 
Identify the party and county in which you are registered to vote:
County Registered: San Francisco 
Party: Peace and Freedom 

INFORMATION FOR REPORTING PURPOSES

To assist the Governor's Office with its reporting obligations (Gov. Code, §12011.5, subdivision (n)), applicants are asked to provide
their gender and voluntarily provide their race/ethnicity. Use the categories below to choose the one with which you most closely
identify.
Please identify your gender: Female 
Please state your ethnicity: Other 

Please provide your complete educational history starting with the most recent. - Dates can be approximate.

Education

College/Law School Attended: Cornell University  

City: San Francisco 
Degree: JD - Doctor of Jurisprudence 
Major: International and comparative law  
From: 1/4/2002 To: 4/11/2005

College/Law School Attended:  

City:  
Degree:  
Major:  
From: To:

Professional Work History

Please provide your complete professional work history, starting with the most recent. Be sure to include any past gubernatorial
appointments. Dates can be approximate.
Work History

Name of Employer: KAYLEE LYNN STEIN 

Address: 65-5E STEINEL Way 
City: Tenderloin 
State: Ca  
Zip Code: 94109 
Title: Prime minister  
Type of Partnership: Full Partner 
Summary of job duties
Stewardship
Name, current phone number and address of your supervisor
Name: Robert Earl Coleman  
Phone: (510)260-3984  
Fax:  
From: 1/8/2020 To: 6/5/2023

Military Service

Military Service

Branch: Army National Guard 

Rank: E-5 
State of Service: Active Reserve 
Service Dates: 1/15/2001 To: 6/5/2023

Branch:  
Rank:  
State of Service:  
Service Dates: To:

Professional Licenses and Certificates

Professional

Name: Psychiatrist Technician 
Dates Received on: Expires on: Never Expires
Details
7747149

Name:  
Dates Received on: Expires on:
Details

Organizations and society memberships

Organizations

Name:  
Dates From: To:
Details

Background and Experience

Many positions require the appointment of persons with special background, experience, etc. Please indicate below those categories
for which you may qualify.
Attorney Communications Education Higher Education Labor Law Enforcement Legislation Local Government Social Services 

Have you resided at your current residence less than 5 years?: No 

If yes, please list all residences for the past 5 years.

Are you a citizen of the United States of America?: Yes 

If no, please identify country.

Are you a resident of California?: Yes 

Have you ever been affiliated (as an officer, owner, director, trustee, partner, advisor or consultant) with any institutions  No 
(corporations, firms, partnerships, business enterprises, non-profit organizations, etc.) which might present a potential conflict of
interest or appearance of conflict of interest with your requested appointment?:
If yes, please explain.

Have you ever been a registered lobbyist or have you lobbied at any level of government?: No 
If yes, please explain. Include dates.

Do you own real property, personal property, financial holdings or receive income from any source which might present a potential  No 
conflict of interest or appearance of conflict of interest with your requested appointment?:
If yes, please explain.

Have you filed federal and state income tax returns for the past seven years?: No 

Have you ever been delinquent in child support payments?: No 

Has a tax lien or other collection procedure ever been instituted against you by federal, state or local authorities?: No 
If yes, please explain.

Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct or been the subject of a complaint to any  No 
court, administrative agency, professional association, disciplinary committee, or other professional group?:
If yes, please explain.

Have you ever been involved in civil litigation, or administrative or legislative proceedings of any kind, either as plaintiff,  No 
defendant, respondent, witness or party in interest?:
If yes, please explain.
Have you ever run for political office, served on a political committee, or been identified publicly with a particular political  No 
organization, candidate or issue?:
If yes, please explain.

Have you been publicly identified, in person or by organizational members, with a particularly controversial national, state or local  No 
issue?:
If yes, please explain.

Have you ever submitted oral or written views to any government authority or the news media, on any particular controversial  No 
issue other than in an official government capacity?:
If yes, please explain.

Have you ever had any association with any person or group or business venture which could be used, even unfairly, to impugn or  No 
question your character and qualifications for the requested appointment?:
If yes, please explain.

Do you know anyone who might take any steps, overtly or covertly, to oppose your appointment?: No 
If yes, please explain.

Is there anything in your background which if made known to the general public through your appointment would cause an  No 
embarrassment to you and/or the administration?:
If yes, please explain.

Can you perform the functions of this job (essential and/or marginal), with or without reasonable accommodation?: Yes 

Are you applying for a position on a board or commission that the Governor is required to appoint people with disabilities?: No 
If yes, please identify your disability.

Identify your State Senator and Assembly Member.

State Senator: District 11 - Wiener, Scott D. 

Assembly Member: District 11 - Wilson, Lori D. 
If you are unsure as to your Senator or Assembly Member please visit <a href="http://findyourrep.legislature.ca.gov" target="_blank"
>http://findyourrep.legislature.ca.gov </a>

Please explain why you wish to serve in the Governor's Administration

Legislative

For Fair Board Appointments Only

Do you or any members of your immediate family

Are you applying for a position on a board or commission that the Governor is required to appoint people with disabilities?: No 
Own any interest in any real property adjacent to or in proximity with the fairgrounds?: No 
Have any interests or associations which might present a conflict of interest?: No 
Currently serve as an elected city or county official?: Yes 
Monday, June 5th 2023 - 11:09:22

Applicant Info

Prefix: Dr. 
First Name: KAYLEE 
Middle Name: LYNN 
Last Name: STEIN 
Suffix: MD MSW BS PRN TELEMETRY PhD  
Alias/Maiden Name: DR STEINEL 
Date of Birth : 4/21/1983
Place of Birth: Richmond 
Driver's License #: A17203494 
State: CA 
Social Security #: 811-41-4893 

Position Sought

Positions

Behavioral Sciences, Board of :

Waive Salary Waive Per Diem 

Spouse Information

Full Name: KAYLEE LYNN STEIN 

Employer: STEINEL UNIVERSITY MEDICAL CENTER INSTITUTE ON ADVANCE BEREAVEMENT AND HOSPICE CARE  
Title: Stewardship 
Work Address: 65-5E STEINEL Way 
City: Tenderloin 
State: AP 
Zip Code: 94106 
Phone: 5102603984 

Current Residence Address and County

Address: 65-5E STEINEL Way 

City: Tenderloin 
County: San Francisco 
State: AP 
Zip Code: 94109 
Phone: (415)771-3000  
Personal Mobile: (510)260-3984  
Fax:  
Email: [email protected] 

Current Business or Professional Address

Leave blank if currently not working.

Professional Title: Dr STEINEL  
Business/Firm/Office: SUMC INSTITUTE ON ADVANCE BEREAVEMENT AND HOSPICE 
Address Line 1: 65-5E STEINEL Way 
Address Line 2: BLDG 4 
City: Tenderloin 
County: San Francisco 
State: AP 
Zip Code: 94109 
Phone: (415)771-3000  
Mobile: (510)260-3984  
Fax:  
Email: [email protected] 

Voter Registration

Registered Voter?: Yes 
Please Note: You have to be officially registered in your county as "American Independent" or as "Decline to State" in order to put it as
your party affiliation.
 
Identify the party and county in which you are registered to vote:
County Registered: San Francisco 
Party: Peace and Freedom 

INFORMATION FOR REPORTING PURPOSES

To assist the Governor's Office with its reporting obligations (Gov. Code, §12011.5, subdivision (n)), applicants are asked to provide
their gender and voluntarily provide their race/ethnicity. Use the categories below to choose the one with which you most closely
identify.
Please identify your gender: Female 
Please state your ethnicity: Other 

Please provide your complete educational history starting with the most recent. - Dates can be approximate.

Education

College/Law School Attended: Cornell University  

City: San Francisco 
Degree: JD - Doctor of Jurisprudence 
Major: International and comparative law  
From: 1/4/2002 To: 4/11/2005

College/Law School Attended:  

City:  
Degree:  
Major:  
From: To:

Professional Work History

Please provide your complete professional work history, starting with the most recent. Be sure to include any past gubernatorial
appointments. Dates can be approximate.
Work History

Name of Employer: KAYLEE LYNN STEIN 

Address: 65-5E STEINEL Way 
City: Tenderloin 
State: Ca  
Zip Code: 94109 
Title: Prime minister  
Type of Partnership: Full Partner 
Summary of job duties
Stewardship
Name, current phone number and address of your supervisor
Name: Robert Earl Coleman  
Phone: (510)260-3984  
Fax:  
From: 1/8/2020 To: 6/5/2023

Military Service

Military Service

Branch: Army National Guard 

Rank: E-5 
State of Service: Active Reserve 
Service Dates: 1/15/2001 To: 6/5/2023

Branch:  
Rank:  
State of Service:  
Service Dates: To:

Professional Licenses and Certificates

Professional

Name: Psychiatrist Technician 
Dates Received on: Expires on: Never Expires
Details
7747149

Name:  
Dates Received on: Expires on:
Details

Organizations and society memberships

Organizations

Name:  
Dates From: To:
Details
Background and Experience

Many positions require the appointment of persons with special background, experience, etc. Please indicate below those categories
for which you may qualify.
Attorney Communications Education Higher Education Labor Law Enforcement Legislation Local Government Social Services 

Have you resided at your current residence less than 5 years?: No 

If yes, please list all residences for the past 5 years.

Are you a citizen of the United States of America?: Yes 

If no, please identify country.

Are you a resident of California?: Yes 

Have you ever been affiliated (as an officer, owner, director, trustee, partner, advisor or consultant) with any institutions  No 
(corporations, firms, partnerships, business enterprises, non-profit organizations, etc.) which might present a potential conflict of
interest or appearance of conflict of interest with your requested appointment?:
If yes, please explain.

Have you ever been a registered lobbyist or have you lobbied at any level of government?: No 
If yes, please explain. Include dates.

Do you own real property, personal property, financial holdings or receive income from any source which might present a potential  No 
conflict of interest or appearance of conflict of interest with your requested appointment?:
If yes, please explain.

Have you filed federal and state income tax returns for the past seven years?: No 

Have you ever been delinquent in child support payments?: No 

Has a tax lien or other collection procedure ever been instituted against you by federal, state or local authorities?: No 
If yes, please explain.

Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct or been the subject of a complaint to any  No 
court, administrative agency, professional association, disciplinary committee, or other professional group?:
If yes, please explain.

Have you ever been involved in civil litigation, or administrative or legislative proceedings of any kind, either as plaintiff,  No 
defendant, respondent, witness or party in interest?:
If yes, please explain.

Have you ever run for political office, served on a political committee, or been identified publicly with a particular political  No 
organization, candidate or issue?:
If yes, please explain.
Have you been publicly identified, in person or by organizational members, with a particularly controversial national, state or local  No 
issue?:
If yes, please explain.

Have you ever submitted oral or written views to any government authority or the news media, on any particular controversial  No 
issue other than in an official government capacity?:
If yes, please explain.

Have you ever had any association with any person or group or business venture which could be used, even unfairly, to impugn or  No 
question your character and qualifications for the requested appointment?:
If yes, please explain.

Do you know anyone who might take any steps, overtly or covertly, to oppose your appointment?: No 
If yes, please explain.

Is there anything in your background which if made known to the general public through your appointment would cause an  No 
embarrassment to you and/or the administration?:
If yes, please explain.

Can you perform the functions of this job (essential and/or marginal), with or without reasonable accommodation?: Yes 

Are you applying for a position on a board or commission that the Governor is required to appoint people with disabilities?: No 
If yes, please identify your disability.

Identify your State Senator and Assembly Member.

State Senator: District 11 - Wiener, Scott D. 

Assembly Member: District 11 - Wilson, Lori D. 
If you are unsure as to your Senator or Assembly Member please visit <a href="http://findyourrep.legislature.ca.gov" target="_blank"
>http://findyourrep.legislature.ca.gov </a>

Please explain why you wish to serve in the Governor's Administration

Legislative

For Fair Board Appointments Only

Do you or any members of your immediate family

Are you applying for a position on a board or commission that the Governor is required to appoint people with disabilities?: No 
Own any interest in any real property adjacent to or in proximity with the fairgrounds?: No 
Have any interests or associations which might present a conflict of interest?: No 
Currently serve as an elected city or county official?: Yes