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Name (please print):_____________________

________________________________________
Work Address:___________________________
________________________________________
Office E-mail:__________________________
________________________________________
Department/Agency: _____________________
________________________________________
Division/Bureau:________________________
________________________________________
Office Telephone:_______________________
________________________________________
Civil Service Title:
________________________________________
Functional Title
(if different):_____________________________
________________________________________
Job Duties:_____________________________
________________________________________


1) Are you currently engaged in, or planning to engage in, any business, trade, profession and/or part-time or full-time employment, paid or unpaid, outside of or in addition to your State employment?
_____ Yes _____No
If no, skip to question 6.

2) Name of Outside Employer(s) or Business(es).______________
Indicate if you are an owner, partner or corporate officer._________________
Address:____________
Type of Business:______________
Description of responsibilities:________________
Specify Days Worked Per Week (i.e. Mon., Tues., Wed., etc.:)________________
Work Hours: __am/pm to ___am/pm

3) Is your current or proposed outside employment or business being performed for or with any other employee(s) or official(s) of your State agency? __Yes __No
If yes, name and title of employee(s) or official(s)._______________
Do you have a supervisor-subordinate relationship with this person(s)? __Yes __No
If yes, explain.___________________

4) Does or will your outside employment or business require/cause you to have contacts with any NJ State agencies, vendors, consultants or casino license holders? __Yes __No
If yes, explain, providing name of the agency, vendor, consultant or casino license holder you will have contacts with, and the nature of those contacts._______________

5) In your current or proposed outside employment or business do you or will you contract with or receive compensation from any New Jersey State agency? __Yes __No
If yes, indicate name of State agency and attach a copy of the contract. If no contract exists, provide a description of your business arrangement with the State agency.___________
If you have a contract with the State, did you receive the approval of the State Ethics Commission prior to entering into the contract? __Yes __No

6) Do you hold a license issued by a New Jersey State agency that entitles you to engage in a particular business profession, trade or occupation? ____Yes ____No.
If yes, type of license. __________________________
When was the license issued? _________________
Is the license active? __________________________

7) Do you currently hold, or plan to hold, any outside voluntary position(s)? __Yes __No
If yes, explain. _________________
Does this position require you to have contacts with any New Jersey State agency? _____Yes _____No
If yes, explain._________________

8) Are you an officer in any professional, trade, business or other organization? __Yes __No
If yes, explain. ________________

9) Are you serving in any public office, or considering appointment or election to any public office? __Yes __No
If yes, what is the position and where is it located?____________
What are the duties of the position? ____________________________
Hours engaged in the elective/appointive office?_______________

10) Do you have an ownership interest in any partnership, corporation, professional service corporation, or any other firm or entity that is (a) performing any service for a New Jersey State agency, (b) directly or indirectly receiving funding from a New Jersey State agency, or (c) regulated by a New Jersey State agency?
__Yes __No
If yes, for each indicate the following:
Name of employer, partnership, corporation or other entity in which you hold an ownership interest.
____________________________
Nature of ownership interest in the partnership, corporation or other entity, and extent of ownership interest:
____________________________
Identify the State agency(ies) with which the entity does business, receives funding, or is regulated.
___________________________

11) Are you or any members of your immediate family* employed by a New Jersey casino licensee or applicant for a N.J. casino license? __Yes __No.
*Immediate family means a spouse, child, parent, or sibling residing in your household.
If yes, state:
Family Member's Name_____________
Relationship:__________________
Name of Casino:______________
Position Held:_________________

I certify that this questionnaire contains no willful misstatement of fact, nor omission of a material fact. I understand that should my State employment and/or outside activity change, I am required to promptly submit a new Outside Activity Questionnaire.
Signature of Employee: ______________
Date:___________

Decision of Immediate Supervisor:
______ Approved ______ Disapproved
Print Name of Immediate Supervisor:_______________
Signature of Supervisor: ___________
Date:____________
Comments:________________

Decision of Ethics Liaison Officer:
______ Approved _______ Disapproved
Signature of Ethics Liaison Officer:__________
Date:_________
Comments:___________________

Notification of decision was provided to employee on: _________
Date:_________

NOTE: Under the Uniform Ethics Code ("UEC") a State employee may appeal an agency Ethics Liaison Officer's decision to disapprove an outside activity. An appeal must be submitted in writing to the State Ethics Commission within 60 days of the employee's receipt of the agency's decision. For more information on appeals, see UEC Section VI.