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STATE ETHICS COMMISSION June 2012 1 1.1 OAQ FORM endstream endobj 365 0 obj [ 715 0 R 625 0 R 574 0 R 626 0 R 642 0 R 727 0 R 718 0 R 719 0 R 623 0 R 573 0 R 624 0 R 643 0 R 726 0 R 725 0 R 721 0 R 405 0 R 396 0 R 621 0 R 572 0 R 622 0 R 641 0 R 724 0 R 723 0 R 398 0 R 400 0 R 401 0 R] endobj 366 0 obj <> endobj 367 0 obj <> endobj 368 0 obj (D:20070925133950Z) endobj 369 0 obj <<>> endobj 370 0 obj [ 406 0 R 619 0 R 583 0 R 620 0 R 652 0 R 407 0 R 409 0 R 412 0 R 617 0 R 584 0 R 618 0 R 653 0 R 677 0 R 615 0 R 576 0 R 616 0 R 645 0 R 700 0 R 701 0 R 699 0 R 679 0 R 680 0 R 698 0 R 681 0 R 613 0 R 575 0 R 614 0 R 644 0 R 696 0 R 697 0 R 691 0 R 611 0 R 571 0 R 612 0 R 640 0 R 693 0 R 692 0 R] endobj 371 0 obj <> endobj 372 0 obj <> endobj 373 0 obj (D:20070925133950Z) endobj 374 0 obj <<>> endobj 375 0 obj [ 422 0 R 609 0 R 581 0 R 610 0 R 650 0 R 423 0 R 413 0 R 421 0 R 607 0 R 582 0 R 608 0 R 651 0 R 418 0 R 417 0 R 419 0 R 420 0 R 415 0 R 416 0 R 674 0 R 587 0 R 567 0 R 635 0 R 636 0 R 672 0 R 671 0 R 670 0 R 669 0 R 668 0 R 667 0 R] endobj 376 0 obj <> endobj 377 0 obj <> endobj 378 0 obj (D:20070925133950Z) endobj 379 0 obj <<>> endobj 380 0 obj [ 429 0 R 633 0 R 578 0 R 634 0 R 647 0 R 430 0 R 435 0 R 434 0 R 431 0 R 436 0 R 437 0 R 433 0 R 432 0 R 439 0 R 446 0 R 454 0 R 442 0 R 449 0 R 631 0 R 580 0 R 632 0 R 649 0 R 445 0 R 447 0 R 455 0 R 444 0 R 440 0 R 453 0 R 450 0 R 451 0 R 441 0 R 452 0 R 443 0 R 448 0 R 470 0 R 629 0 R 579 0 R 630 0 R 648 0 R 461 0 R 469 0 R 464 0 R 460 0 R 462 0 R 467 0 R 466 0 R 463 0 R 459 0 R 468 0 R 465 0 R] endobj 381 0 obj [ 478 0 R 476 0 R 473 0 R 628 0 R 577 0 R 627 0 R 646 0 R 475 0 R 474 0 R 566 0 R 479 0 R 520 0 R 543 0 R 525 0 R 565 0 R 538 0 R 531 0 R 536 0 R 560 0 R 559 0 R 539 0 R 477 0 R 527 0 R 540 0 R 524 0 R 552 0 R 549 0 R] endobj 382 0 obj <> endobj 383 0 obj <> endobj 384 0 obj (D:20070925133950Z) endobj 385 0 obj <<>> endobj 386 0 obj [ 485 0 R 605 0 R 534 0 R 606 0 R 563 0 R 484 0 R 528 0 R 544 0 R 523 0 R 557 0 R 551 0 R 481 0 R 480 0 R 545 0 R 486 0 R 761 0 R 766 0 R 771 0 R 483 0 R] endobj 387 0 obj <> endobj 388 0 obj <> endobj 389 0 obj <> endobj 390 0 obj <> endobj 391 0 obj <> endobj 392 0 obj <> endobj 393 0 obj <> endobj 394 0 obj ( 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.\r\r 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.\r) endobj 395 0 obj (DefaultFlow) endobj 396 0 obj <>/F 4/MK <<>>/P 1 0 R/Parent 498 0 R/Rect [ 541.3 439.951 560.454 461.951]/Subtype /Widget/Type /Annot>> endobj 397 0 obj <> endobj 398 0 obj <>/F 4/MK <<>>/P 1 0 R/Parent 497 0 R/Rect [ 27.575 224.862 46.7287 246.862]/Subtype /Widget/Type /Annot>> endobj 399 0 obj <> endobj 400 0 obj <>/DA (/Helv 12 Tf 0 g)/DV 394 0 R/F 4/FT /Tx/Ff 4097/MK <<>>/P 1 0 R/Rect [ 29.7693 15.7683 593.077 244.769]/Subtype /Widget/T (PageTwoFootNote)/TU (Foot note)/Type /Annot/V ( 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.\r\r 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.\r)>> endobj 401 0 obj <>/F 4/MK <<>>/P 1 0 R/Parent 498 0 R/Rect [ 27.5981 141.535 46.4245 163.535]/Subtype /Widget/Type /Annot>> endobj 402 0 obj (D:20070925133950Z) endobj 403 0 obj <> endobj 404 0 obj <> endobj 405 0 obj <>/F 4/MK <<>>/P 1 0 R/Parent 497 0 R/Rect [ 190.592 439.951 209.746 461.951]/Subtype /Widget/Type /Annot>> endobj 406 0 obj <>/DA (/Arial 12 Tf 0 g)/DS 722 0 R/DV 411 0 R/F 4/FT /Tx/Ff 41947137/MK <<>>/P 4 0 R/RV (

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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?

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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.

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If you have a contract with the State, did you receive the approval of the State Ethics Commission prior to entering into the contract?

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9\) Are you serving in any public office, or considering appointment or election to any public office?

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8\) Are you an officer in any professional, trade, business or other organization?

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11\) Are you or any members of your immediate family* employed by a New Jersey casino licensee or applicant for a N.J. casino license?

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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?

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ĢƵ

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 \(e.g. Real Estate, Teaching\)?

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7\) Do you currently hold, or plan to hold, any outside voluntary position\(s\)?

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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?

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Do you have a supervisor-subordinate relationship with this person\(s\)?

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

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If yes, name and title of employee\(s\) or official\(s\).

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