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 Yes, you must answer question 2.

2) Name of Outside Employer(s) or Business(es).______________

Indicate if you are an owner, partner or corporate officer._________________

Address:________________________________

Type of Business:_______________________________

Describe 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.___________________

Does your outside employment or business require/cause you to have contacts with other NJ State agencies, vendors, consultants or casino license holders? ____ 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 or applicants₁, medical cannabis permit holders, applicants, or entities₂, or personal use cannabis license holders, applicants, or entities₃? ____Yes ____No

If yes, explain, providing name of the agency, vendor, consultant, casino license holder, medical cannabis permit holder, applicant, or entity, or personal use cannabis license holder, applicant, or entity 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, permit, registration, certification, certificate or commission issued by a New Jersey State agency that entitles you to engage in a particular business profession, trade or occupation? (e.g, Real Estate, Teaching)

______Yes ______No.

If yes, type of license, permit, registration, certification, certificate or commission. __________________________

When was the license, permit, registration, certification, certificate or commission issued? _________________

Is the license, permit, registration, certification, certificate or commission 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 applicant₁? _____Yes _____No.

*Immediate family means a spouse, civil union partner, domestic partner, child, parent, or sibling residing in your household.

If yes, state:
Family Member's Name_________________

Relationship:_______________________

Name of Casino:_____________________

Position Held:_______________________

 

12)  Are you or any members of your immediate family employed by a New Jersey medical cannabis permit holder, applicant, or entity₂?_____Yes _____No.

*Immediate family means a spouse, civil union partner, domestic partner, child, parent, or sibling residing in your household.

If yes, state:
Family Member's Name_________________

Relationship:______________________

Name of Entity:_____________________

Position Held:________________________

 

13) Are you or any members of your immediate family employed by a New Jersey personal use cannabis license holder, applicant, or entity₃? _____Yes _____No.

*Immediate family means a spouse, civil union partner, domestic partner, child, parent, or sibling residing in your household.

If yes, state:
Family Member's Name_________________

Relationship:______________________

Name of Entity:_____________________

Position Held:________________________

 

14) Do you or an immediate family member hold an interest in any casino license holders or applicants₁, medical cannabis permit holders, applicants, or entities₂, or personal use cannabis license holders, applicants, or entities₃? _____Yes _____No.
*If yes, explain, providing the name of the casino license holder, medical cannabis permit holder, applicant, or entity, or personal use cannabis license holder, applicant, or entity in which you hold an interest, the percentage of your ownership interest and whether the entity is a professional service corporation.

 __________________________________________

 

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.

 

1.  Casino license holder or applicant means holder of, or an applicant for, a casino license or in any holding or intermediary company with respect thereto, as defined by the “Casino Control Act,” P.L.1977, c. 110 (C.5:12-1 et seq.). It may also include any holder of, or applicant for, a license, permit, or other approval to conduct Internet gaming, or any holding or intermediary company with respect thereto; any Internet gaming affiliate of any holder of, or applicant for, a casino license, or any holding or intermediary company with respect thereto; or any business, association, enterprise, or other entity that is organized, in whole or in part, for the purpose of promoting, advocating for, or advancing the interests of the Internet gaming industry generally or any Internet gaming-related business or businesses in connection with any cause, application, or matter.

2.  Medical cannabis permit includes a medical cannabis cultivator permit, medical cannabis manufacturer permit, medical cannabis dispensary permit, or clinical registrant permit; medical cannabis entities may also include medical cannabis permit holders or applicants, any entity that employs any certified medical cannabis handler to perform transfers or deliveries of medical cannabis, or any holding or intermediary company with respect thereto.

3.  Personal use cannabis license includes a cannabis cultivator, cannabis manufacturer, cannabis wholesaler, cannabis distributor, cannabis retailer, or cannabis delivery service license; personal use cannabis entities may also include personal use cannabis license holders or applicants, any entity that employs or uses a certified personal use cannabis handler to perform work for or on behalf of a licensed cannabis establishment, distributor, or delivery service, or any holding or intermediary company with respect to thereto.