Personal and Business Relationship Disclosure Form

NJSEC BDF 07/1
PERSONAL AND BUSINESS RELATIONSHIPS DISCLOSURE FORM
Instructions:
A State officer or employee, or special State officer or employee, of a State agency as defined in N.J.S.A 52:34-10.11
who is involved in the procurement process must complete this form in full. Involvement in the procurement process
means drafting, reviewing, evaluating or making contract awards or substantively assisting in any of those tasks, or
authorizing payments under those contracts.
The completed form must be filed with the head of the State agency in which the State officer or employee, or special
State officer or employee, holds office or employment. A copy of the completed form must be forwarded to the State
Ethics Commission, PO Box 082, Trenton, NJ 08625-0082. (Hand delivery address: 28 West State Street, Room 1407,
Trenton, NJ 08608).
The completed form must be reviewed by the filer on an annual basis. A new form must be completed any time there is a
material change to any response.
A. General Information
Date of Statement
First Name:
M.I.
Last Name:
Business Mailing Address
Street Address:
P.O. Box:
City:
State:
Zip Code:
Daytime Telephone Number:
Email Address:
Position:
Department or Agency:
B.
Please complete the following questions for the period covering five years prior to the date of this statement.
1. Please specify below any interest you hold in any firm, association, partnership, corporation or other business
organization, including any subsidiary or related company thereof, that has sought or been awarded a public contract with
your agency or any agency with which you have involvement in the procurement process.
"Interest" means any ownership or control of any profits or assets of a business organization. Include both the name of
the business organization and the nature of your interest (number of shares held, percentage of partnership, etc.).
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NJSEC BDF 07/1
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2. Please list below any professional relationship with any person, firm, association, partnership, corporation or other
business organization, including any subsidiary or related company thereof, that has sought or been awarded a public
contract with your agency or any agency with which you have involvement in the procurement process. Include both the
name of the business organization and the nature of the professional relationship.
3. Please list below any personal relationship with any principal officer or director of any firm, association, partnership,
corporation or other business organization, including any subsidiary or related company thereof, that has sought or
been awarded a public contract with your agency or any agency with which you have involvement in the procurement
process. Include the name of the principal officer or director, the name of the business organization and the nature of
the personal relationship.
I certify that the information on this form, to the best of my knowledge and belief, is true,
correct and accurate. I understand that I may be subject to discipline and/or prosecution if I
have omitted or falsified information.
(Signature)
Date