Outside Employment Questionnaire for Special State Officers & Special State Employees

Name: *

UCID:

NJIT Position: *

NJIT Address (if any):

Email Address:

NJIT Telephone:

Check One *

Special State Officer (i.e. Trustee)

Special State Employee(i.e. adjunct, temporary employee, seasonal)

Outside Employment

1. Are you currently engaged in any business, trade, profession and/or part-time employment in addition to your NJIT position? *

Yes

If yes, please list the name of outside employer(s) or business(es):

Address of outside employer or business:

Type of business:

Description of your responsibilities for outside employer or business:

Specific days worked per week:

Work hours:

2. Is your business or employment being performed for or with any other employee or official of NJIT?

Yes

3. 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 applicants, medical cannabis permit holders, applicants, or entities, or personal use cannabis license holders, applicants, or entities?

Yes

If yes, please explain:

4. 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, realtor, notary)?

Yes

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

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

License, permit, registration, certification, certificate or commission is:

Active

Inactive

5. Do you hold outside voluntary position(s)? *

Yes

If yes, please list:

6. Are you an officer in any trade or business organization? *

Yes

If yes, please list:

7. Are you serving in any elected or appointed public office? *

Yes

If yes, identify the public office:

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.)

8. Are any relatives employed by the State agency in which you serve? *

Yes

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

9. Are any relatives employed by or, through partnership or corporate office, hold an interest in any firm performing any service for NJIT or directly or indirectly receiving funding from NJIT? *

Yes

If yes, name of family member:

10. Do you or an immediate family member hold an interest in any casino license holders or applicants, medical cannabis permit holders, applicants, or entities, or personal use cannabis license holders, applicants, or entities? *

Yes

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:

Please provide your NJIT supervisor’s name as he/she must review and approve your Outside Employment Questionnaire form: *

Supervisor name

Certification

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. This questionnaire must be completed and returned to the Ethics Office within seven (7) days. I have been given access to the Uniform Ethics Code, NJIT’s Supplemental Code of Ethics, and Plain Language Guide to New Jersey's Executive Branch Ethics Standards. I have reviewed the documents and I understand that I am bound by them.

Signature *

Enter your full name

Date *