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STATE OF NEW JERSEY
OUTSIDE EMPLOYMENT QUESTIONNAIRE
FOR SPECIAL STATE OFFICERS and
SPECIAL STATE EMPLOYEES


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 or will your outside employment or business require/cause you to have contacts with any NJ State agencies, vendors, consultants, 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:___________________________________

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: ___________________________
__________________________

Relatives:
(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:

______________________________________________
______________________________________________

11. 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 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

 

_____________________________________

Date                                    

 

 

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.

 

 

Last updated : September 9th, 2021