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Name (please print):

Work Address:
Telephone Number:
Civil Service Title:
Functional Title
(if different):
Job Duties:

1) Are you currently engaged in any business, trade, profession
and/or part-time or full-time employment 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). Please indicate if you are an owner, partner or corporate officer._________________________________


Type of Business:_______________________________

Describe responsibilities:____________________________

Outside Employment (please specify): Days Worked per Week:____________________________

Hours Worked: Per Day___________________ Per Week______________________________

Is your employment or business being performed for or with any other Department employee or
official? ____Yes ___ No . Name of employee or official and title _________________________

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.________________________________________________________

3) Do you hold a license issued by a State agency that entitles you to engage in a particular business,
profession, trade or occupation? ____Yes ____No. If yes, type of license ___________________
When was license issued? _________________________ Active or inactive? ___________________

4) Do you currently hold or plan to hold outside voluntary position(s)? _____Yes _____ No
If yes, explain. __________________________________________________________

5) Are you an officer in any professional organization? _______ Yes _________ No
If yes, explain. ____________________________________________________________________

6) Are you serving in any public office, or considering appointment or election to any public office?
_____ Yes _____ No
What is the type of elective/appointive position?_________________________________________
What are your duties?______________________________________________________________
Hours engaged in elective/appointive activity: Per Day_____ Per Week_____ Per Month _____

7. Do any members of your immediate family, either through employment with or through a partnership or a corporate office, hold an interest in any firm or entity that is (a) performing any service for the State of New Jersey, (b) directly or indirectly receiving funding from the State, or (c) regulated by the State?
_______ Yes _______ No

Family Member's Name ___________________________ Relationship:______________________
Nature of employment ______________________________________________________________
Duration: ______Permanent ______Temporary

8) Are any members of your immediate family employed by a New Jersey casino or an applicant for a
N.J. casino license? _________Yes __________No.

Family Member's Name___________________________ Relationship:______________________
Name of Casino:___________________________________________________________________

I certify that this questionnaire contains no willful misstatement of fact nor omission of material fact and that after it is submitted, any future activity subject to disclosure will be reported before I engage in such activity.
_______________________________________ ___________________
Signature of Employee Date

Immediate Supervisor (circle one)

Approved Disapproved



Comments and/or reason for disapproval:







Ethics Liaison Officer (circle one)

Approved Disapproved



Comments and/or reasons for disapproval:






Please provide the employee with a copy of the
Approved / Disapproved Form.