DVA State Ethics OAQ Form

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New Jersey State Ethics Commission Outside Activity Questionnaire

Employee Details

Questionnaire

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?
2) Name of Outside Employer(s) or Business(es). Please indicate if you are an owner, partner, or corporate officer.
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?
Do you have a supervisor-subordinate relationship with this person(s)?
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 applicants ¹, medical cannabis permit holders, applicants, or entities ², or personal use cannabis license holders, applicants, or entities ³?
If yes, explain, providing name of the agency, vendor, consultant, casino license holder or applicant, 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.

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.

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?
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?
Questions 2 - 5 have been skipped due to your answer of "No" to Question 1
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)?
7) Do you currently hold, or plan to hold, any outside voluntary position(s)?
If yes, explain.
Does this position require you to have contacts with any New Jersey State agency?
8) Are you an officer in any professional, trade, business or other organization?
If yes, explain.
9) Are you serving in any public office, or considering appointment or election to any public 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?
If yes, for each indicate the following:
11) Are you or any members of your immediate family employed by a New Jersey casino license holder or applicant ¹ ? Immediate family means a spouse, civil union partner, domestic partner, child, parent, or sibling residing in your household.

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.

12) Are you or any members of your immediate family employed by a New Jersey medical cannabis permit holder, applicant, or entity ² ? Immediate family means a spouse, civil union partner, domestic partner, child, parent, or sibling residing in your household.

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.

13) Are you or any members of your immediate family employed by a New Jersey personal use cannabis license holder, applicant, or entity ³ ? Immediate family means a spouse, civil union partner, domestic partner, child, parent, or sibling residing in your household.

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.

14) Do you or an immediate family member hold an interest in any casino license holders or applicants ¹, medical cannabis permit holders, applicants, or entities ² , or personal use cannabis license holders, applicants, or entities ³ ? Immediate family means a spouse, civil union partner, domestic partner, child, parent, or sibling residing in your household.
If yes, explain, by providing the name of the casino license holder or applicant, 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.

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.

I certify that this questionnaire contains no willful misstatement of fact or 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.

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