Revised 5/2017 SEC/jf
505 Ramapo Valley Road, Mahwah, NJ 07430-1680
Phone (201) 684-7504 Fax (201) 684-7508
PLEASE NOTE: The Outside Activity Questionnaire MUST be completed by ALL EMPLOYEES whether
or not there is outside employment or activity. INCOMPLETE OR OUT OF DATE FORMS WILL NOT BE
Name: Telephone/Ext:
Date: Full-Time: Part-Time: Email:
Division: Academic Affairs Administration & Finance Enrollment Management/Student Affairs Institutional Advancement
Unit: Title:
Job Duties: (briefly describe)
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?
YES (Answer questions 2 through 9)
NO (Answer questions 4 through 9)
Managers MUST obtain approval through Employee Relations P to beginning outside employment.
Name of outside employer/business (Please indicate if you are an owner, partner or corporate officer):
Type of business:
Description of responsibilities:
Number of days worked per week:
Hours worked: Per day: Per week:
Is your current or proposed outside employment or business being performed for or with any other College
employee or official? YES
(if yes, name and title) NO
Do you have a supervisor-subordinate relationship with this person? YES NO
If yes, please explain:
Does or will your outside employment or business require/cause you to have contacts with other NJ State
agencies, vendors, consultants or casino license holders? YES
If yes, please explain (provide name of agency, vendor, consultant or casino license holder you will have
contact with and the nature of those contacts):
3. In your current or proposed outside employment or business, do you or will you contract with or receive
compensation for any New Jersey State agency? YES
If yes, indicate name of State agency and attach a copy of the contract. If no contract exists, provide
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? YES
4. Do you hold a license issued by a State agency that entitles you to engage in a particular business,
profession, trade or occupation? YES
If Yes, type of license:
License issue date: Active Inactive
5. Do you currently hold or plan to hold outside voluntary positions? YES NO
If yes, please explain:
Does this position require you to have contacts with any New Jersey State agency? YES NO
If yes, please explain:
6. Are you an officer in any professional, trade or business organization? YES NO
If yes, please explain and give name of organization:
7. Are you serving in any public office, or considering appointment or elections to any public office?
Type of elective/appointive position AND location:
Description of duties:
Number of hours engaged in elective/appointive activity: Per day Week Month
8. Do you have 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? YES
NO If yes, for each please indicate the following:
Name of employer, partnership, corporation or other entity in which you hold an ownership interest:
Nature of ownership interest in partnership, corporation or other entity ownership and extent of
ownership interest:
Identity of the State agency(ies) with which the entity does business, receives funding or is regulated:
9. Are you or any member of your immediate family* employed by a New Jersey casino licensee or
applicant for a N.J. casino license?
(Immediate family means spouse, child, parent or sibling residing in your
Family Member’s name: Relationship:
Casino Name:
Position held:
I certify that the above employment, if any, does not:
a) Constitute a conflict of interest,
b) Occur at a time when I am expected to perform my work for Ramapo College,
c) Diminish my efficiency in performing my work at Ramapo College
I further certify that this questionnaire contains no willful misstatement or fact or omission of
material facts and that after it is submitted, any future activity subject to disclosure will be reported
before I engage in such activity.
Employee Signature Date
UNIT HEAD DECISION Approved Disapproved
Unit Head Name (Print):
Unit Head Signature:
Unit Head reviews, signs and forwards form to the Office of Employee Relations.
ELO Name (print):
ELO Signature:
Notification of decision provided to employee on:
NOTE; Under the Uniform Ethics Code (“UEC”) a State employee may appeal an agency Ethics Liaison
Officer’s decision to disapprove an outside activity. An appeal must be submitted in writing to the State
Ethics Commission within 60 days of the employee’s receipt of the agency’s decision. For more information
on appeals, see UEC Section VI.
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