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Name:   ____________________________________

State Position: _______________________________

State Agency:  _______________________________

State Agency Address:  ________________________

(Check One)     Special State Officer _______      Special State Employee _______

Contact Information:

Telephone Number:  ___________________________

Email Address (Optional):  ______________________

Outside Employment:

1. Are you currently engaged in any business, trade, profession and/or part-time employment in addition to your State position?  ____Yes  ____ No

2.  Name of outside employer or business: ______________________ 

Address:  ______________________________________
Type of Business:  _______________________________
Describe Responsibilities: _________________________

3.  Is your business or employment being performed for or with any other employee or official of your State agency?  ____Yes  ____No

4.  Does your outside employment or business require/cause you to have contacts with NJ State vendors, consultants or casino license holders?  ____Yes  ____No
If yes, explain:___________________________________

5.  Do you hold a license, permit, registration, certification, certificate or commission issued by a State agency that entitles you to engage in a particular business, profession, trade or occupation (ie. Law, Teaching)?  ___Yes ___No
If yes, type of license, permit, registration, certification, certificate or commission:______________________________
License, permit, registration, certification, certificate or commission is ____Active  ____Inactive

6.  Do you hold outside voluntary position(s)?  ____Yes  ____No
If yes, please list:  ________________________________

7.  Are you an officer in any trade or business organization?  ____Yes  ____No
If yes, please list:  _________________________________________________________

8.  Are you serving in any elected or appointed public office?  ____Yes  ____No
If yes, identify the public office and explain the duties: ___________________________

(For purposes of this section, “relative” means your spouse, domestic partner, civil union partner or your or your spouse/partner’s parent, child, brother, sister, aunt uncle, niece, nephew, grandparent, or grandchild, whether the relative is related to you or your spouse/partner by blood, marriage or adoption.)

9.  Are any relatives employed by the State agency on which you serve?
____Yes  ____No 

If yes, please provide name of relative(s):

10.  Are any relatives employed by or, through partnership or corporate office, hold an interest in any firm performing any service for the State agency or directly or indirectly receiving funding from the State agency on which you serve?   ____Yes  ____No  

If yes, name of family member:


I certify that this questionnaire contains no willful misstatement of fact or omission of material fact and that after it is submitted, any future activity subject to disclosure will be reported.




Signature of special State officer or employee






Last updated : January 4th 2019