Fillable DISCLOSURE OF NAMES OF FAMILY MEMBERS WHO ARE (North Shore Community College)

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DISCLOSURE OF NAMES OF FAMILY MEMBERS WHO ARE (North Shore Community College)

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DISCLOSURE OF NAMES OF FAMILY MEMBERS WHO
ARE STATE EMPLOYEES
Disclosure Required by G.L. c. 268A, Sec. 6B
Name of Applicant for Employment: _____________________
Date: ____________
Is your spouse, parent, brother, sister or child, or the spouse of your parent, brother, sister
or child, a state employee?
___ Yes ____ No
If you answered Yes, please list below the name(s) of any state employee who is your
spouse, parent, brother, sister or child, or who is the spouse of your parent, brother, sister
or child, and indicate their relationship to you. Please also list the name of the state
agency that employs those relatives.
NOTE: For purposes of this disclosure, a “state employee” is a person holding a paid or
unpaid office, position, employment or membership in a Massachusetts state agency. For
purposes of this disclosure, a “state agency” is any department of Massachusetts state
government, including any department or agency within the executive, legislative or
judicial branch, and all councils thereof and thereunder, and any division, board, bureau,
commission, institution, tribunal or other instrumentality within such department or
agency, and any independent state authority, commission, instrumentality or agency, but
NOT INCLUDING an agency of a county, city or town.
Name of Relative Relationship to Applicant Name of State Agency
____________________ _____________________ ____________________
____________________ _____________________ ____________________
____________________ _____________________ ____________________
____________________ _____________________ ____________________
____________________ _____________________ ____________________
____________________ _____________________ ____________________
____________________ _____________________ ____________________
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DISCLOSURE OF NAMES OF FAMILY MEMBERS WHO ARE (North Shore Community College)

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Completed 26 July 2020

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